Benefits Summary2020-21 - State of Utah Look inside for important information about how to use your PEHP benefits.
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2020-21
Benefits Summary
State of Utah
Look inside for important
information about how
to use your PEHP benefits.
PROUDLY SERVING UTAH PUBLIC EMPLOYEES
State of Utah 2020-21 » Introduction
State of Utah
2020-21
State of Utah Benefits Summary
STATE OF UTAH
Benefits Summary
Effective July 2020
© 2020 Public Employees Health Program
This Benefits Summary should be used in conjunction with the PEHP Master Policy. It contains information that only
applies to PEHP subscribers who are employed by the State of Utah and their eligible dependents. Members of any other
PEHP plan should refer to the applicable publications for their coverage.
It is important to familiarize yourself with the information provided in this Benefits Summary and the PEHP Mas-
ter Policy to best utilize your medical plan. The Master Policy is available by calling PEHP. You may also view it at
www.pehp.org.
This Benefits Summary is for informational purposes only and is intended to give a general overview of the benefits avail-
able under those sections of PEHP designated on the front cover. This Benefits Summary is not a legal document and does
not create or address all of the benefits and/or rights and obligations of PEHP. The PEHP Master Policy, which creates the
rights and obligations of PEHP and its members, is available upon request from PEHP and online at www.pehp.org. All
questions concerning rights and obligations regarding your PEHP plan should be directed to PEHP.
The information in this Benefits Summary is distributed on an “as is” basis, without warranty. While every precaution has
been taken in the preparation of this Benefits Summary, PEHP shall not incur any liability due to loss, or damage caused
or alleged to be caused, directly or indirectly by the information contained in this Benefits Summary.
The information in this Benefits Summary is intended as a service to members of PEHP. While this information may be
copied and used for your personal benefit, it is not to be used for commercial gain.
The employers participating with PEHP are not agents of PEHP and do not have the authority to represent or bind PEHP.
5/13/20
WWW.PEHP.ORG PAGE 1
State of Utah 2020-21 » Table of Contents
Table of Contents
Introduction Other Benefits
WELCOME/CONTACT INFO . . . . . . . . . . . . . . . . . . . . . . . . . 3 PEHP DENTAL
BENEFIT CHANGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 »Preferred Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
»Traditional Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
AUTISM PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
»Basic HSA Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
PEHP VALUE PROVIDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 »Discount HSA Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
PEHP ONLINE TOOLS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 »Regence Expressions Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
PEHP LIFE AND AD&D
Medical Benefits »Group Term Life Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
»Accidental Death and Dismemberment . . . . . . . . . . . . . . . .33
MEDICAL NETWORKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 »Accident Weekly Indemnity . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
UNDERSTANDING YOUR BENEFITS GRID . . . . . . .11 »Accident Medical Expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
UNDERSTANDING IN-NETWORK PROVIDERS 12 VISION
HEALTH SAVINGS ACCOUNTS . . . . . . . . . . . . . . . . . . . . 13 »Eyemed plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
»Opticare plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
PEHP FLEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
BENEFITS GRIDS
»The STAR HSA Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 External Vendors
»Traditional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
UTAH RETIREMENT SYSTEMS . . . . . . . . . . . . . . . . . . . . .42
»Consumer Plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
BLOMQUIST HALE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
WELLNESS AND VALUE-ADDED BENEFITS MET LIFE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
»PEHP Healthy Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
UTAH EDUCATIONAL SAVINGS . . . . . . . . . . . . . . . . . . .47
»PEHPplus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
»PEHP WeeCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 MOUNTAIN AMERICA CREDIT UNION . . . . . . . . . . .49
»Life Assistance Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 LIBERTY MUTUAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
SECURITY SERVICE FEDERAL CREDIT UNION . . . . .53
THE STANDARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
WWW.PEHP.ORG PAGE 2
State of Utah 2020-21 » Contact Information
Welcome to PEHP
We want to make accessing and understanding your healthcare benefits simple. This Benefits Summary
contains important information on how best to use PEHP’s comprehensive benefits.
Please contact the following PEHP departments or affiliates if you have questions.
ON THE WEB PEHP FLEX$
» . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.pehp.org » PEHP FLEX$ Department . . . . . . . . . . . . . . . . . . . 801-366-7503
Create a PEHP for Members account at www.pehp.org . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7703
to review your claims history, get important information
through our Message Center, see a comprehensive list of HEALTH SAVINGS ACCOUNTS (HSA)
your coverages, find and compare providers in your network, » PEHP FLEX$ Department . . . . . . . . . . . . . . . . . . . 801-366-7503
access Healthy Utah rebate information, check your FLEX$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7703
account balance, and more.
» HealthEquity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 866-960-8058
CUSTOMER SERVICE . . . . . . . . . . . . . . . . . . . . . . . .www.healthequity.com/stateofutah
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347 PRENATAL AND POSTPARTUM PROGRAM
» PEHP WeeCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-366-7400
Weekdays from 8 a.m. to 5:30 p.m. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7400
Have your PEHP ID or Social Security number on hand for . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .www.pehp.org/weecare
faster service. Foreign language assistance available.
WELLNESS AND DISEASE MANAGEMENT
PREAUTHORIZATION » PEHP Healthy Utah . . . . . . . . . . . . . . . . . . . . . . . . 801-366-7300
» Inpatient hospital preauthorization . . . . . . . . 801-366-7755 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7754 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .www.pehp.org/healthyutah
» PEHP Health Coaching . . . . . . . . . . . . . . . . . . . . 801-366-7300
MENTAL HEALTH/SUBSTANCE ABUSE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300
PREAUTHORIZATION
» PEHP Customer Service . . . . . . . . . . . . . . . . . . . .801-366-7755
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347 VALUE-ADDED BENEFITS PROGRAM
» PEHPplus . . . . . . . . . . . . . . . . . . . . . . . . . . . www.pehp.org/plus
PRESCRIPTION DRUG BENEFITS » Blomquist Hale . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-926-9619
» PEHP Customer Service . . . . . . . . . . . . . . . . . . . .801-366-7555 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.blomquisthale.com
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
» Express Scripts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-903-4725 ONLINE ENROLLMENT HELP LINE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.express-scripts.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-366-7410
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7410
SPECIALTY PHARMACY
CLAIMS MAILING ADDRESS
» Accredo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-501-7260
PEHP
560 East 200 South
GROUP TERM LIFE AND AD&D
Salt Lake City, UT 84102-2004
» PEHP Life and AD&D . . . . . . . . . . . . . . . . . . . . . . . 801-366-7495
WWW.PEHP.ORG PAGE 3
State of Utah 2020-21 » Benefit Changes
Benefits Changes & Reminders
Chronic Medications Covered Health Benefit Advisors
Before Deductible Need help deciding which plan to choose,
This is a benefit for STAR HSA Plan whether to be covered by more than one
members who no longer have to meet plan, or different cost options for a service?
their deductible before getting certain Call a PEHP Health Benefit Advisor at 801-
chronic medications covered under the 366-7555.
plan. www.pehp.org for details.
E-Care
New Prescription Cost Tool Consider consulting a doctor remotely
Find drug options for your health with your smartphone from Intermountain
condition, compare prices at different Connect Care (all networks) or University of
pharmacies, and see if cash back is Utah Health Virtual Visits (Summit only). It’s
available for your medication. Visit convenient and costs less.
www.pehp.org for details.
Crisis & Life Assistance
Get Up to $2,000 in Cash Back Counseling
You can now share in the savings when You have access to counseling services
you choose a lower-cost provider. Find with Blomquist Hale Employee Assistance.
out about cash back services using PEHP’s Crisis counseling is also available 24/7
new Cost Comparison Tool. Look for and always confidential. PEHP pays 100%
the green phone with a dollar sign. Visit of the cost. Call 1-800-926-9619 for an
www.pehp.org for details. appointment.
Send Secure Messages to PEHP
Have a question or can’t find what you’re
looking for online? Log in to PEHP for
Members and send us your questions via
the Message Center. Click the Message
Center icon after you login to your PEHP
account.
WWW.PEHP.ORG PAGE 4
State of Utah 2020-21 » Autism Program
Autism Spectrum Disorder Benefit
The benefit covers behavioral health treatment (ABA Therapy).
A brief overview of PEHP’s Autism Spectrum Disorder coverage:
» Please call PEHP (801-366-7555 » Mental health and speech therapy services
or 800-765-7347) for information require Preauthorization.
about which autism spectrum disorders
» No benefits for services received from
and services are covered.
out-of-network Providers. List of
» Therapeutic care includes services in-network providers is available
provided by speech therapists, at PEHP for Members or by calling
occupational therapists, or physical PEHP (801-366-7555 or 800-765-7347).
therapists.
» Regular medical benefits will apply (see
» Eligible Autism Spectrum Disorder benefits grid for applicable co-pay and
services do not accrue separately, coinsurance).
and are subject to the medical plan’s
visit limits, regular cost sharing limitations
– deductibles, co-payments,
and coinsurance – and would apply
to the out-of-pocket maximum.
WWW.PEHP.ORG PAGE 5
State of Utah 2020-21 » PEHP Value Providers
PEHP Value Providers
PEHP Value Providers
MEDICAL
MEDICAL
The STAR Plan » 25% discount on what you would normally pay an in-network provider
Traditional Plan » $10 office co-pay
The
SALTSTAR
LAKEPlan
CITY » 25% discount on what you would normally
OREMpay an in-network provider
Midtown
TraditionalClinic
Plan » $10 office co-pay Blendtec Health and Wellness Clinic
230 South 500 East, Suite 510 | 801-320-5660 1206 S 1680 W | 801-225-1281
SALT LAKE CITY OREM
RC Willey Employee
Midtown Clinic Clinic Blendtec Health and Wellness Clinic
LEHI
2301South
230 South500
300East,
West | 801-464-7900
Suite 510 | 801-320-5660 801-225-1281
OnSite CareW
1206 S 1680 at| Mountain Point Medical
WesTech 3000 Triumph Blvd, Ste. 320 | 801-753-4600
RC WilleyWellness
Employee Center
Clinic LEHI
3605
2301 SSouth
West300 West| 801-506-0000
Temple | 801-464-7900 OnSite Care at Mountain Point Medical
WesTech Wellness 3000 Triumph Blvd, Ste. 320 | 801-753-4600
NORTH SALT LAKECenter
3605 S West Temple
Orbit Employee Clinic| 801-506-0000
845 Overland St. | 801-951-5888
NORTH SALT LAKE
FJM
OrbitClinic
Employee Clinic
31
845NOverland
RedwoodSt.Rd, Suite 2 | 801-624-1634
| 801-951-5888 E-CARE/TELEMEDICINE
Visit a doctor online anytime, anywhere.
FJM Clinic
CLEARFIELD
31 N Redwood Rd, Suite 2 | 801-624-1634 » EyeE-CARE/TELEMEDICINE
infections
Futura Onsite Clinic » Painful urination
11 H Street | 801-774-3265 Visit a doctor online anytime, anywhere.
» Joint pain or strains
CLEARFIELD » Minor
Eye infections
skin problems
Futura
LAYTON Onsite Clinic » Painful urination
11
Onsite Care| 801-774-3265
H Street at Davis Hospital » JointHSA
STAR painPlan » $59 per visit or $10 per visit
or strains
1580 W. Antelope Dr., Suite 110 | 801-807-7699 after deductible;
» Minor For UofU virtual visits: $49 per
skin problems
LAYTON visit or $10 per visit after deductible
Onsite STAR HSA Plan
Plan» »$59
$10per
pervisit
visitor $10 per visit
OGDENCare at Davis Hospital Traditional
after deductible; For UofU virtual visits: $49 per
1580 W. Antelope Dr., Suite 110 | 801-807-7699
FJM Clinic visit or $10 per visit
Intermountain after deductible
Connect Care » available on all
1104 Country Hills Dr., Ste. 110 | 801-624-1633 networks
OGDEN Traditional Plan » $10 per visit
FJM Clinic University
Intermountainof Utah Health
Connect Virtual
Care Visits on
» available » all
1104 Country Hills Dr., Ste. 110 | 801-624-1633 available
networks on Summit network only
University of Utah Health Virtual Visits »
available on Summit network only
Check with your employer to see which medical and dental plans are available to you. You must be enrolled in an active PEHP medical plan to visit a medical
clinic. You must be enrolled in an active PEHP dental plan to visit a dental clinic.
Check with your employer to see which medical and dental plans are available to you. You must be enrolled in an active PEHP medical plan to visit a medical
clinic. You must be enrolled in an active PEHP dental plan to visit a dental clinic.
WWW.PEHP.ORG PAGE 6
State of Utah 2020-21 » PEHP Value Providers
PEHP Value Providers
COLONOSCOPY
Get Cash Back » Get cash back* when you get your colonoscopy from one of these Value
Providers. You must call PEHP prior to service to be eligible for cash back. You need to get the
colonoscopy in the provider’s office or at an ambulatory surgical center to be eligible for cash back
as this doesn’t apply to hospitals, even if your doctor determines you must do it there. Remember
you’ll always get the best pricing when you use a PEHP Value Provider.
Utah Gastroenterology Granite Peaks Gastroenterology
If you’re on the Advantage Network, there is only • 1393 E Sego Lilly Dr., Sandy
one Utah Gastroenterology location where cash back • 3000 N Triumph Blvd Ste 330, Lehi
is available. Summit, Capital, and Preferred Network
members may use any of the facilities listed below and Revere Health
receive cash back. • 1055 N. 500 W., Provo
• 6360 S 3000 E Ste 310, SLC (Advantage) • 1175 E. 50 S., American Fork
• 620 Medical Dr Ste 205, Bountiful
• 1250 E 3900 S Ste 360, SLC Preventive Colonoscopy 50+
You must call PEHP prior to service to
• 13953 S Bangerter Pkwy, Draper get cash back. The cash back applies even
• 12391 S 4000 W, Riverton when it’s preventive and covered at 100%.
• 3000 N Triumph Blvd, Ste 340, Lehi Tip: Be sure the anesthesia is considered
“moderate or conscious” sedation as general
anesthesia isn’t covered as part of the
preventive service unless pre-authorized
through PEHP. Also be aware that sometimes
the colonoscopy can result in additional
treatment or diagnosis where you would be
*Please note cash back is subject to income taxes. responsible for some of the cost based on
your benefit cost share.
PRESCRIPTION ASSISTANCE PROGRAMS
PEHP has identified several medication-assistance programs which may help to reduce the cost of
your medication. See if you qualify.
Rx Help Centers® Patient Advocate Foundation®
http://rxhelpcenter.org/ http://www.patientadvocate.org/
Patient Access Network Foundation® HealthWell Foundation®
https://panfoundation.org/index.php/en/ https://www.healthwellfoundation.org/
WWW.PEHP.ORG PAGE 7
State of Utah 2020-21 » PEHP Value Providers
PEHP Value Providers
PEHPLABORATORIES
Value Providers
LABORATORIES
Visit these labs for exclusive PEHP member savings.
MULTIPLE LOCATIONS BOUNTIFUL
Visit these labs for exclusive PEHP member savings.
The following laboratories have more than one Bountiful Health Center Lab
location.
MULTIPLE ForLOCATIONS
the location near you, visit the 390 N Main St. | 801-294-1150
BOUNTIFUL
Provider Lookup
The following at www.pehp.org.
laboratories have more than one Advantage network
Bountiful Health only Lab
Center
location. For the location near you, visit the 390 N Main St. | 801-294-1150
Accupath Diagnostics MURRAY network only
Provider Lookup at www.pehp.org. Advantage
Advantage and Summit networks Intermountain Central Lab
Accupath Diagnostics
Cedar Diagnostics LLC 5252
MURRAYS Intermountain Dr. | 801-535-8163
Advantage
Advantage and Summit networks
and Summit networks Summit networkCentral
Intermountain only Lab
Cedar Diagnostics LLC 5252 S Intermountain Dr. | 801-535-8163
Esoterix SALT LAKE
Summit CITYonly
network
Advantage
Advantage and Summit
network onlynetworks IHC Health Center Salt Lake Clinic
Esoterix 333
SALTS 900 E | 801-535-8163
LAKE CITY
Labcorp Inc Advantage
Advantage
Advantage network
and Summitonlynetworks IHC Healthand Summit
Center Salt networks
Lake Clinic
333 S 900 E | 801-535-8163
Labcorp
Pathology IncAssociates Medical Labs OUT-OF-STATE
Advantage and Summit networks
Advantage and Summit
Summit network only networks ALBUQUERQUE, N.M.
Pathology Associates Medical Labs Tricore Reference Laboratories
OUT-OF-STATE
Quest Diagnostics 1001 Woodward | 505-938-8803
Pl. NEN.M.
Summit ALBUQUERQUE,
Summit network only
network only Summit network only
Tricore Reference Laboratories
Quest Diagnostics 1001 Woodward Pl. NE | 505-938-8803
Summit network only Summit network only
Check with your employer to see which medical and dental plans are available to you. You must be enrolled in an active PEHP medical plan to visit a medical
clinic. You must be enrolled in an active PEHP dental plan to visit a dental clinic.
7/15/2020
Check with your employer to see which medical and dental plans are available to you. You must be enrolled in an active PEHP medical plan to visit a medical
clinic. You must be enrolled in an active PEHP dental plan to visit a dental clinic.
8
7/15/2020
WWW.PEHP.ORG PAGE
State of Utah 2020-21 » PEHP Online Tools
PEHP Online Tools
Access Benefits and Claims Access Your Pharmacy Account
WWW.PEHP.ORG WWW.EXPRESS-SCRIPTS.COM
Access important benefit tools and information by Create an account with Express Scripts, PEHP’s
creating an online personal account at www.pehp.org. pharmacy benefit manager, and get customized
» Receive important messages about your benefits and information that will help you get your medications
quickly and at the best price.
coverage through our Message Center.
Go to www.express-scripts.com to create an account. All
» See your claims history — including medical, dental,
you need is your PEHP ID card and you’re on your way.
and pharmacy. Search claims histories by member,
plan, and date range. You’ll be able to:
» Become a savvy consumer using our Cost & Quality » Check prices.
Tools. » Check an order status.
» View and print plan documents, such as forms and » Locate a pharmacy.
Master Policies.
» Refill or renew a prescription.
» Get a simple breakdown of the PEHP benefits in
which you’re enrolled. » Get mail-order instructions.
» Track your biometric results and access Healthy » Find detailed information specific to your plan,
Utah rebates and resources. such as drug coverage, co-pays, and cost-saving
alternatives.
» Access your FLEX$ account.
» Cut down on clutter by opting in to paperless
delivery of explanation of benefits (EOBs). Opt to
receive EOBs by email, rather than paper forms
through regular mail, and you’ll get an email every
time a new one is available.
» Change your mailing address.
Find a Provider
WWW.PEHP.ORG
Looking for a provider, clinic, or facility that is
contracted with your plan? Look no farther than
www.pehp.org. Go online to search for providers by
name, specialty, or location.
WWW.PEHP.ORG PAGE 9State of Utah 2020-21 » Medical Networks
Summit Advantage
Steward Health, MountainStar, Intermountain Healthcare (IHC)
and University of Utah Health Care providers and facilities. You can also
providers and facilities. You can also see see Summit providers on the Advantage
Advantage providers on the Summit network, but your benefits will pay less.
network, but your benefits will pay less.
Participating Hospitals
Beaver County Salt Lake County (cont.)
Participating Hospitals Beaver Valley Hospital Primary Children’s Medical Center
Beaver County Salt Lake County (cont.) Milford Valley Memorial Hospital Riverton Hospital
Beaver Valley Hospital Riverton Children’s Unit Box Elder County San Juan County
Milford Valley Memorial Hospital St. Marks Hospital Bear River Valley Hospital Blue Mountain Hospital
Salt Lake Regional Medical Center San Juan Hospital
Box Elder County Cache County
University of Utah Hospital
Bear River Valley Hospital Logan Regional Hospital Sanpete County
University Orthopaedic Center
Brigham City Community Hospital Gunnison Valley Hospital
San Juan County Carbon County
Cache County Castleview Hospital Sanpete Valley Hospital
Blue Mountain Hospital
Cache Valley Hospital Sevier County
San Juan Hospital Davis County
Carbon County Davis Hospital Sevier Valley Hospital
Sanpete County
Castleview Hospital Intermountain Layton Hospital
Gunnison Valley Hospital Summit County
Davis County Sanpete Valley Hospital Duchesne County Park City Medical Center
Lakeview Hospital Uintah Basin Medical Center
Sevier County Tooele County
Davis Hospital
Sevier Valley Hospital Garfield County Mountain West Medical Center
Duchesne County Garfield Memorial Hospital
Summit County Uintah County
Uintah Basin Medical Center
Park City Medical Center Grand County Ashley Regional Medical Center
Garfield County Moab Regional Hospital
Tooele County Utah County
Garfield Memorial Hospital
Mountain West Medical Center Iron County American Fork Hospital
Grand County Cedar City Hospital Orem Community Hospital
Uintah County
Moab Regional Hospital Utah Valley Hospital
Ashley Regional Medical Center Juab County
Iron County Central Valley Medical Center Wasatch County
Utah County
Cedar City Hospital Heber Valley Medical Center
Mountain View Hospital Kane County
Juab County Timpanogos Regional Hospital Kane County Hospital Washington County
Central Valley Medical Center Mountain Point Medical Center Dixie Regional Medical Center
Millard County
Kane County Wasatch County Delta Community Hospital Weber County
Kane County Hospital Heber Valley Medical Center Fillmore Community Hospital McKay-Dee Hospital
Millard County Washington County Salt Lake County Out-of-State – Colorado
Delta Community Hospital Dixie Regional Medical Center Alta View Hospital St. Mary’s Hospital – Grand Junction
Fillmore Community Hospital Intermountain Medical Center Southwest Memorial Hospital – Cortez
Weber County
Salt Lake County Ogden Regional Medical Center The Orthopedic Specialty Hospital (TOSH)
Huntsman Cancer Hospital LDS Hospital
Out-of-State – Colorado
Jordan Valley Hospital
St. Mary’s Hospital – Grand Junction
Jordan Valley Hospital - West
Southwest Memorial Hospital – Cortez
Lone Peak Hospital
Primary Children’s Medical Center
Preferred
Non-Contracted Providers Consists of all providers and facilities
PEHP doesn’t pay for any services from certain in both the Summit and Advantage
providers, even if you have an out-of-network
benefit. Find participating providers and
networks.
see a list of Non-Contracted Providers at
www.pehp.org.
WWW.PEHP.ORG PAGE 10State of Utah 2020-21 » Medical Benefits Grid » Tr
State of Utah 2020-21 » Understanding Your Benefit Grid
MEDICAL BENEFITS GRID: W
Refer to the Master Policy for specific cri
Understanding Your Benefits Grid as well as information on limitations and
Percentages indicate your share of PE
Traditional (Non-HSA) In-Network Provider O
Summit, Advantage & Preferred
DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS
Plan year Deductible
Does not apply to Out-of-Pocket Maximum 1 Single plans: $350
Double/family plans: $350 per person, $700
One person cannot meet more than $350
Plan year Out-of-Pocket Maximum** 2 Single plans: $3,000
Double plans: $3,000 per person, $6,000 per
Family plans: $3,000 per person, $9,000 per
One person cannot meet more than $3,000
ANNUAL PREVENTIVE CARE
Preventive services allowed by Affordable Care Act No charge 4
Annual physical exam, immunizations.
See full list at www.pehp.org/preventiveservices
PROFESSIONAL SERVICES
PEHP e-Care Medical: $10 co-pay per visit N
PEHP Value Clinics $10 co-pay per visit N
1 MEDICAL
Primary Care Visits | Includes office surgeries and inpatient visits DEDUCTIBLE
$25 co-pay per visit
The set dollar amount
IHC: $35that you
co-pay permust
visit for Summit
4
pay for yourselfand
and/or yournetworks
Preferred family
members before PEHP begins
University toMedical
of Utah pay forGroup:
covered medical$35 co-pay per
benefits. visit plans
Some
might also have$35
Specialist Visits | Includes office surgeries and inpatient visits a separate
co-pay perpharmacy
visit 4
deductible. IHC: $45 co-pay per visit for Summit
and Preferred networks
2
PLAN YEAR OUT-OF-POCKETUniversity of Utah Medical Group:
MAXIMUM $45 co-pay per visit
The maximum dollar amount that you
Surgery and Anesthesia 20% after deductible 4
and/or your family pays each year for
CO-PAY Emergency Room Specialist Visits covered medical$35 co-pay per
services visitform
in the $
A specific amount you pay directly to a providerDiagnostic
when youTests, Labs, X-rays
of copayments and coinsurance
20% after deductible(and 4
receive covered services. This can be either a fixed dollar amount or a
Mental Health and Substance Abuse deductibles for $35 co-pay per Some
STAR plans). visit 4
percentage of the PEHP In-Network Rate.
No preauthorization required for outpatient service. plans might alsoUniversity
have separate
of Utahout-of-
Medical Group:
Inpatient services require preauthorization pocket maximums for mental
$45 co-pay health &
per visit
IN-NETWORK
In-network benefits apply when you receive covered services from in-
PRESCRIPTION DRUGS | For Drug Tiersubstance abuse
info, see the Covered and
Drug Listfor specialty drug
at www.pehp.org
network providers. You are responsible to pay the applicable copayment. charges.
30-day Pharmacy Tier 1: $10 co-pay P
Retail only Tier 2: 25% of discounted cost. m
OUT-OF-NETWORK $25 minimum, no maximum co-pay a
If your plan allows the use of out-of-network providers, out-of-network Tier 3: 50% of discounted cost.
benefits apply when you receive covered services. You are responsible to pay $50 minimum, no maximum co-pay
the applicable co-pay, plus the difference between thePharmacy
90-day billed amount and Tier 1: $20 co-pay P
PEHP’s In-Network Rate. Maintenance only Tier 2: 25% of discounted cost. m
$50 minimum, no maximum co-pay a
IN-NETWORK RATE Tier 3: 50% of discounted cost.
The amount in-network providers have agreed to accept as payment in full. $100 minimum, no maximum co-pay
If you use an out-of-network provider, you will be
*Youresponsible to pay your
pay 20% of the In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge
portion of the costs as well as the difference between what the providerto.bills
have an agreement with you not Any amount above the In-Network Rate may be billed to you and will not count toward your
**Some services on your plan are payable at a reduced benefit of 50% of In-Network Rate or 30% of In-Network Rate. These servic
and the In-Network Rate (balance billing). In this case, the allowed amount is For more definitions,
maximum. Deductible may apply. Refer to the Master Policy for specific criteria for the benefits listed above, as well as information
based on our in-network rates for the same service. please see the Master Policy.
WWW.PEHP.ORG
WWW.PEHP.ORG PAGE 11State of Utah 2020-21 » Understanding In-Network Providers
Understanding In-Network Providers
It’s important to understand the difference between
in-network and out-of-network providers and how the In-
Network Rate works to avoid unexpected charges. Negotiate a Price
Don’t get Balance Billed: Although non-contracted
In-Network Rate providers are under no obligation to charge within
the In-Network Rate, consider negotiating the
Doctors and facilities contracted in your network — in-
network providers — have agreed not to charge more than price before you receive the service to avoid being
PEHP’s In-Network Rate for specific services. Your benefits balance billed.
are often described as a percentage of the In-Network
Rate. With in-network providers, you pay a predictable
amount of the bill: the remaining percentage of the In- The amount you pay for charges above the In-Network Rate
Network Rate. For example, if PEHP pays your benefit at won’t apply to your deductible or out-of-pocket maximum.
80% of In-Network Rate, your portion of the bill generally
won’t exceed 20% of the In-Network Rate.
Consider Your Options
Balance Billing Carefully choose your network based on the group of
medical providers you prefer or are more likely to see. See
It’s a different story with out-of-network providers. They the Medical Networks comparison in this book or go to
may charge more than the In-Network Rate unless they www.pehp.org and log in to PEHP for Members to see which
have an agreement with you not to. These doctors and network includes your doctors.
facilities, who aren’t a part of your network, have no pricing
Ask questions before you get medical care. Make sure
agreement with PEHP. The portion of the benefit PEHP pays
every person and every facility involved is contracted in
is based on what we would pay a n in-network provider.
your network.
You’ll be billed the full amount that the provider charges
above the In-Network Rate. This is called “balance billing.” Although out-of-network providers are under no
obligation to charge within the In-Network Rate, consider
Understand that charges to you may be substantial if you
negotiating the price before you receive the service to
see an out-of-network provider. Your plan generally pays a
avoid being balance billed.
smaller percentage of the In-Network Rate, and you’ll also
be billed for any amount charged above the In-Network Learn More » Your Network and Your Money
Rate.
WWW.PEHP.ORG PAGE 12State of Utah 2020-21 » Medical Benefits Grid » HSAs
Health Savings Accounts
About Health Savings Account (HSA) HSA Eligibility
An HSA is a tax-advantaged, interest-bearing account. To be eligible for the HSA the following things must
Your money goes in tax free, grows tax free, and can apply to you:
be spent on qualified health expenses tax free. An HSA » You’re not participating in or covered by a flexible
can be a great way to save for health expenses in both
spending account (FSA) or HRA or their balances
the short and long term.
will be $0 on or before June 30.
An HSA is similar to a flexible spending account; you
» You’re not covered by another health plan (unless
contribute pre-tax dollars to pay for eligible health
expenses. it’s another HSA-qualified plan).
An HSA has several advantages. You never have to » You’re not covered by Medicare or TRICARE.
forfeit what you don’t spend. Your money carries » You’re not a dependent of another taxpayer.
over from year-to-year and even from employer-to-
employer. All the while, an HSA can earn tax-free
interest in a savings account. Banking with HealthEquity
The STAR Plan employer HSA contributions for 2020-21 PEHP has an arrangement with HealthEquity to handle
will be $909.22 for a single plan and $1,826.76 for double your HSA. The State of Utah will make your HSA
plans, and $1,918.54 for family plans. Contributions will contributions through PEHP to HealthEquity into your
be frontloaded semi-annually, half by the end of July account. You are responsible for the management of
2020 and half by the end of January 2021. your HSA funds once they are in the account.
Consumer Plus Plan employer HSA contributions for
2020-21 will be $1,824.68 for a single plan and $3,649.62
for a double and family plan. Contributions will be
For More Information
frontloaded semi-annually, half by the end of July 2020 For more information about HSAs go to:
and half by the end of January 2021. www.pehp.org/thestarplan, www.ustreas.gov, or
You can also contribute to an HSA much like you www.irs.gov.
would a 401(k). You decide how many pre-tax dollars
you want withheld from each paycheck, and earnings
grow tax free.
Consumer Plus Plan
Eligible HSA expenses include deductibles and Co- For Consumer Plus Plan members double covered
Insurance, as well as health expenses that are eligible to through the State, be aware of the IRS limit and notify
be paid with a medical flexible spending account. PEHP to only accept IRS limit.
2020 HSA IRS limits
Single: $3,550
Double/Family: $7,100
55+ Catch-up contribution: $1,000
Learn more:
www.healthequity.com/stateofutah
WWW.PEHP.ORG PAGE 13State of Utah 2020-21 » FLEX$
PEHP Flexible Spending Plan — FLEX$
Save Money With FLEX$ Using Your FLEX$ Card
Sign up for PEHP’s flexible spending account – FLEX$ You will automatically receive a FLEX$ Benefit Card
— and save. FLEX$ saves you money by reducing your at no extra cost. It works just like a credit card and
taxable income. Each year you set aside a portion of is accepted at most eligible merchants that take
your pre-tax salary for your account. That money can be MasterCard.
used to pay eligible out-of-pocket health expenses and
dependent day care expenses. Use the card at participating locations and your eligible
charges will automatically deduct from your FLEX$
account.
FLEX$ Options For places that don’t accept the FLEX$ card, simply pay
for the charges and submit a copy of the receipt and a
FLEX$ has three options, two for medical expenses
claim form to PEHP for reimbursement.
(one exclusive to The STAR HSA Plan) and another for
dependent day care. You may contribute a minimum You will be responsible to keep all receipts for tax and
of $130 and a maximum of $2,750 a year for healthcare audit purposes. Also, PEHP may ask for verification of
expenses and up to $5,000 a year for dependent daycare any charges.
expenses.
FLEX$ HEALTHCARE ACCOUNT
Important Considerations
If you are on the Traditional Plan, use this account to » You must plan ahead wisely and set aside only what
pay for eligible out-of-pocket health expenses for you or you will need for eligible expenses each year. FLEX$
your eligible dependents. Pay for such things as out-of- is a use-it-or-lose-it program – only $500 will carry
pocket deductibles and co-pays, prescription glasses, over from year to year.
laser eye surgery, and more. Go to www.pehp.org for a
list of eligible items. » The total amount you elect to withhold throughout
the year for medical expenses will be immediately
LIMITED PURPOSE FLEXIBLE SPENDING ACCOUNT available as soon as the plan year begins.
If you are enrolled in The STAR HSA or Consumer Plus
» You can’t contribute to a health savings account
Plan, you can also choose to enroll in a Limited Purpose
(HSA) while you’re enrolled in healthcare FLEX$.
Flexible Spending Account. The pre-tax monies you
However, you may have a dependent day care FLEX$
choose to fund this account can be used for eligible
or a limited FSA and contribute to an HSA.
dental and vision expenses, and after you have met
The STAR Plan deductible you can use these funds for
eligible medical expenses. Enrollment
FLEX$ DEPENDENT DAYCARE ACCOUNT
This account may be used for eligible day-care expenses ENROLL ONLINE
for your eligible dependents to allow you or your Log in to your online personal account at
spouse to work or to look for work. You may have this www.pehp.org. Click on online enrollment.
account with any PEHP medical plan.
WWW.PEHP.ORG PAGE 14StateState of Utah
of Utah 2020-21
2020-21 » Medical
» Medical Benefits
Benefits » The»STAR
Grid Grid STARHSA
HSAPlan
MEDICAL BENEFITS GRID: WHAT YOU PAY
Refer to the Master Policy for specific criteria for the benefits listed below,
as well as information on limitations and exclusions.
Percentages indicate your share of PEHP’s In-Network Rate.
STAR HSA In-Network Provider Out-of-Network Provider*
Summit, Advantage & Preferred Balance billing may apply
DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS
Plan year Deductible Single plans: $1,500
Double/family plans: $3,000
One person or a combination can meet the $3,000 double/family deductible
Plan year Out-of-Pocket Maximum Single plans: $2,500
Includes amounts applied to Deductibles, Co-Insurance and prescription drugs Double plans: $5,000
Family plans: $7,500
One person or a combination can meet the $7,500 family maximum
ANNUAL PREVENTIVE CARE
Preventive services allowed by Affordable Care Act No charge 40% after deductible
Annual physical exam, immunizations.
See full list at www.pehp.org/preventiveservices
PROFESSIONAL SERVICES
PEHP e-Care Medical: $10 co-pay per visit after Not applicable
deductible
PEHP Value Clinics Medical: 20% after deductible Not applicable
Primary Care Visits | Includes office surgeries and inpatient visits 20% after deductible 40% after deductible
Specialist Visits | Includes office surgeries and inpatient visits 20% after deductible 40% after deductible
Surgery and Anesthesia 20% after deductible 40% after deductible
Emergency Room Specialist Visits 20% after deductible 20% after deductible
Diagnostic Tests, Labs, X-rays 20% after deductible 40% after deductible
Mental Health and Substance Abuse 20% after deductible 40% after deductible
No preauthorization required for outpatient service.
Inpatient services require preauthorization
PRESCRIPTION DRUGS | All pharmacy benefits for The STAR Plan are subject to the deductible. For Drug Tier info, see the Covered Drug List at www.pehp.org
30-day Pharmacy Tier 1: $10 co-pay Plan pays up to the discounted cost,
Retail only Tier 2: 25% of discounted cost. minus the preferred co-pay, if
$25 minimum, no maximum co-pay applicable. Member pays any balance
Tier 3: 50% of discounted cost.
$50 minimum, no maximum co-pay
90-day Pharmacy Tier 1: $20 co-pay Plan pays up to the discounted cost,
Maintenance only Tier 2: 25% of discounted cost. minus the preferred co-pay, if
$50 minimum, no maximum co-pay applicable. Member pays any balance
Tier 3: 50% of discounted cost.
$100 minimum, no maximum co-pay
*You pay 20% of the In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they
have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not count toward your deductible or out-of-pocket maximum.
WWW.PEHP.ORG PAGE 15
WWW.PEHP.ORGState of Utah 2020-21 » Medical Benefits Grid » The STAR HSA Plan
State of Utah 2020-21 » Medical Benefits Grid » STAR HSA
In-Network Provider Out-of-Network Provider*
Balance billing may apply
PRESCRIPTION DRUGS | All pharmacy benefits for The STAR Plan are subject to the deductible. For Drug Tier info, see the Covered Drug List at www.pehp.org
Specialty Medications, retail pharmacy Tier A: 20%. No maximum co-pay Plan pays up to discounted cost,
Up to 30-day supply Tier B: 30%. No maximum co-pay minus the applicable co-pay.
You pay any balance
Specialty Medications, office/outpatient Tier A: 20%. No maximum co-pay Tier A: 40%. No maximum co-pay
Up to 30-day supply Tier B: 30%. No maximum co-pay Tier B: 50%. No maximum co-pay
Specialty Medications, through Home Health or Accredo Tier A: 20%. $150 maximum co-pay Not covered
Up to 30-day supply Tier B: 30%. $225 maximum co-pay
Tier C: 20%. No maximum co-pay
OUTPATIENT FACILITY SERVICES
Outpatient Facility and Ambulatory Surgical Center 20% after deductible 40% after deductible
Urgent Care Facility 20% after deductible 40% after deductible
Emergency Room 20% after deductible 20% after deductible
Medical emergencies only, as determined by PEHP.
If admitted, inpatient facility benefit will be applied
Ambulance (ground or air) 20% after deductible
Medical emergencies only, as determined by PEHP
Diagnostic Tests, Labs, X-rays 20% after deductible 40% after deductible
Chemotherapy, Radiation, and Dialysis 20% after deductible 40% after deductible
Dialysis from out-of-network provider requires Preauthorization
Physical and Occupational Therapy 20% after deductible 40% after deductible
Outpatient – Up to 20 combined visits per plan year.
INPATIENT FACILITY SERVICES
Medical & Surgical 20% after deductible 40% after deductible
All out-of-network facilities and some in-network facilities require preathorization.
See Master Policy for details
Skilled Nursing Facility 20% after deductible 40% after deductible
Non-custodial. Up to 60 days per plan year. Requires preauthorization
Hospice 20% after deductible 40% after deductible
Rehabilitation 20% after deductible 40% after deductible
Up to 45 days per plan year. Requires preauthorization
Mental Health & Substance Abuse 20% after deductible 40% after deductible
Requires Preauthorization
WWW.PEHP.ORG PAGE 16State of Utah 2020-21 » Medical Benefits Grid » The STAR HSA Plan
State of Utah 2020-21 » Medical Benefits Grid » STAR HSA
In-Network Provider Out-of-Network Provider*
Balance billing may apply
MISCELLANEOUS SERVICES
Adoption | See Master Policy for benefit limits 20% after deductible, up to $4,000 per adoption
or up to $4,000 per lifetime for ART
Allergy Serum 20% after deductible 40% after deductible
Chiropractic care | Up to 10 visits per plan year 20% after deductible Not covered
Durable Medical Equipment 20% after deductible 40% after deductible
Some DME requires preauthorization. Visit www.pehp.org for complete list. Summit Network: Alpine Home Medical
See Master Policy for benefit limits
Medical Supplies 20% after deductible 40% after deductible
See Master Policy for benefit limits
Home Health/Skilled Nursing 20% after deductible 40% after deductible
Up to 60 visits per plan year
Injections 20% after deductible 40% after deductible
Includes allergy injections. See above for allergy serum
Infertility Services | Select services only. See Master Policy for details. 50% after deductible 70% after deductible
Temporomandibular Joint Dysfunction 50% after deductible 70% after deductible
Non-surgical. Up to $1,000 lifetime maximum
WWW.PEHP.ORG PAGE 17State
State of
of Utah 2020-21 »» Medical
Utah 2020-21 Medical Benefits Grid »» Traditional
Benefits Grid Traditional
MEDICAL BENEFITS GRID: WHAT YOU PAY
Refer to the Master Policy for specific criteria for the benefits listed below,
as well as information on limitations and exclusions.
Percentages indicate your share of PEHP’s In-Network Rate.
Traditional (Non-HSA) In-Network Provider Out-of-Network Provider*
Summit, Advantage & Preferred Balance billing may apply
DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS
Plan year Deductible Single plans: $350
Does not apply to Out-of-Pocket Maximum Double/family plans: $350 per person, $700 per family
One person cannot meet more than $350
Plan year Out-of-Pocket Maximum** Single plans: $3,000
Double plans: $3,000 per person, $6,000 per double
Family plans: $3,000 per person, $9,000 per family
One person cannot meet more than $3,000
ANNUAL PREVENTIVE CARE
Preventive services allowed by Affordable Care Act No charge 40% after deductible
Annual physical exam, immunizations.
See full list at www.pehp.org/preventiveservices
PROFESSIONAL SERVICES
PEHP e-Care Medical: $10 co-pay per visit Not applicable
PEHP Value Clinics $10 co-pay per visit Not applicable
Primary Care Visits | Includes office surgeries and inpatient visits $25 co-pay per visit 40% after deductible
IHC: $35 co-pay per visit for Summit
and Preferred networks
University of Utah Medical Group:
$35 co-pay per visit
Specialist Visits | Includes office surgeries and inpatient visits $35 co-pay per visit 40% after deductible
IHC: $45 co-pay per visit for Summit
and Preferred networks
University of Utah Medical Group:
$45 co-pay per visit
Surgery and Anesthesia 20% after deductible 40% after deductible
Emergency Room Specialist Visits $35 co-pay per visit $35 co-pay per visit
Diagnostic Tests, Labs, X-rays 20% after deductible 40% after deductible
Mental Health and Substance Abuse $35 co-pay per visit 40% after deductible
No preauthorization required for outpatient service. University of Utah Medical Group:
Inpatient services require preauthorization $45 co-pay per visit
PRESCRIPTION DRUGS | For Drug Tier info, see the Covered Drug List at www.pehp.org
30-day Pharmacy Tier 1: $10 co-pay Plan pays up to the discounted cost,
Retail only Tier 2: 25% of discounted cost. minus the preferred co-pay, if
$25 minimum, no maximum co-pay applicable. Member pays any balance
Tier 3: 50% of discounted cost.
$50 minimum, no maximum co-pay
90-day Pharmacy Tier 1: $20 co-pay Plan pays up to the discounted cost,
Maintenance only Tier 2: 25% of discounted cost. minus the preferred co-pay, if
$50 minimum, no maximum co-pay applicable. Member pays any balance
Tier 3: 50% of discounted cost.
$100 minimum, no maximum co-pay
*You pay 20% of the In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they
have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not count toward your deductible or out-of-pocket maximum.
**Some services on your plan are payable at a reduced benefit of 50% of In-Network Rate or 30% of In-Network Rate. These services do not apply to any out-of-pocket
WWW.PEHP.ORG PAGE 18
maximum. Deductible may apply. Refer to the Master Policy for specific criteria for the benefits listed above, as well as information on limitations and exclusions.
WWW.PEHP.ORGState of Utah 2020-21 » Medical Benefits Grid » Traditional
State of Utah 2020-21 » Medical Benefits Grid » Traditional
In-Network Provider Out-of-Network Provider*
Balance billing may apply
SPECIALTY DRUGS | For Drug Tier info, see the Covered Drug List at www.pehp.org
Specialty Medications, retail pharmacy Tier A: 20%. No maximum co-pay Plan pays up to discounted cost,
Up to 30-day supply Tier B: 30%. No maximum co-pay minus the applicable co-pay.
You pay any balance
Specialty Medications, office/outpatient Tier A: 20% after deductible. Tier A: 40% after deductible.
Up to 30-day supply No maximum co-pay No maximum co-pay
Tier B: 30% after deductible. Tier B: 50% after deductible.
No maximum co-pay No maximum co-pay
Specialty Medications, through Home Health or Accredo Tier A: 20%. $150 maximum co-pay Not covered
Up to 30-day supply Tier B: 30%. $225 maximum co-pay
Tier C: 20%. No maximum co-pay
OUTPATIENT FACILITY SERVICES
Outpatient Facility and Ambulatory Surgical Center 20% after deductible 40% after deductible
Urgent Care Facility $45 co-pay per visit 40% after deductible
Emergency Room 20% of In-Network Rate, 20% of In-Network Rate,
Medical emergencies only, as determined by PEHP. minimum $150 co-pay per visit minimum $150 co-pay per visit
If admitted, inpatient facility benefit will be applied
Ambulance (ground or air) 20% after deductible
Medical emergencies only, as determined by PEHP
Diagnostic Tests, Labs, X-rays – Minor 20% after deductible 40% after deductible
For each test allowing $350 or less, when the only services performed are diagnostic
testing
Chemotherapy, Radiation, and Dialysis 20% after deductible 40% after deductible
Dialysis from out-of-network provider requires Preauthorization
Physical and Occupational Therapy Applicable co-pay per visit 40% after deductible
Outpatient – Up to 20 combined visits per plan year.
INPATIENT FACILITY SERVICES
Medical & Surgical 20% after deductible 40% after deductible
All out-of-network facilities and some in-network facilities require preathorization.
See Master Policy for details
Skilled Nursing Facility 20% after deductible 40% after deductible
Non-custodial. Up to 60 days per plan year. Requires preauthorization
Hospice 20% after deductible 40% after deductible
Rehabilitation 20% after deductible 40% after deductible
Up to 45 days per plan year. Requires preauthorization
Mental Health & Substance Abuse 20% after deductible 40% after deductible
Requires Preauthorization
WWW.PEHP.ORG PAGE 19State of Utah 2020-21 » Medical Benefits Grid » Traditional
State of Utah 2020-21 » Medical Benefits Grid » Traditional
In-Network Provider Out-of-Network Provider*
Balance billing may apply
MISCELLANEOUS SERVICES
Adoption | See Master Policy for benefit limits 20% after deductible, up to $4,000 per adoption
or up to $4,000 per lifetime for ART
Allergy Serum 20% after deductible 40% after deductible
Chiropractic care | Up to 10 visits per plan year Applicable office co-pay per visit Not covered
Durable Medical Equipment 20% after deductible 40% after deductible
Some DME requires preauthorization. Visit www.pehp.org for complete list. Summit Network: Alpine Home Medical
See Master Policy for benefit limits
Medical Supplies 20% after deductible 40% after deductible
See Master Policy for benefit limits
Home Health/Skilled Nursing 20% after deductible 40% after deductible
Up to 60 visits per plan year
Injections 20% after deductible 40% after deductible
Includes allergy injections. See above for allergy serum
Infertility Services | Select services only. See Master Policy for details. 50% after deductible 70% after deductible
Temporomandibular Joint Dysfunction** 50% after deductible 70% after deductible
Non-surgical. Up to $1,000 lifetime maximum
WWW.PEHP.ORG PAGE 20State
State of of Utah
Utah 2020-21
2020-21 » Consumer
» Consumer Plus
Plus » Benefits
Plan Grids
» Benefits Grids
Important Notice: Consumer Plus is administered by its own Master Policy. The benefits are very different from the
Traditional or STAR plans. Find details in the Consumer Plus Master Policy.
You may not select Consumer Plus unless you are currently on The STAR Plan.
If you choose Consumer Plus, you must enroll in an HSA-qualified plan the next enrollment period.
MEDICAL BENEFITS GRID: WHAT YOU PAY
Refer to the Master Policy for specific criteria for the benefits listed below,
as well as information on limitations and exclusions.
Consumer Plus Percentages indicate your share of PEHP’s In-Network Rate.
(HSA-Qualified) In-Network Provider Out-of-Network Provider*
Summit, Advantage & Preferred Balance billing may apply
DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS
Plan year Deductible Single plans: $3,000
Double/family plans: $6,000
One person or a combination can meet the $6,000 double/family deductible
Plan year Out-of-Pocket Maximum Single plans: $6,050
Includes amounts applied to Deductibles, Co-Insurance and prescription drugs Double/family plans: $12,100
One person can only meet $8,150, or a combination can meet the $12,100 double/family maximum
WELLCARE PROGRAM | ANNUAL ROUTINE CARE
Affordable Care Act Preventive Services No charge 50% of In-Network Rate after
See Master Policy for complete list deductible
Vision Screening No charge 50% of In-Network Rate after
One time between ages 3 and 5 deductible
Pediatric Dental Services** 30% of In-Network Rate after 50% of In-Network Rate after
Routine cleaning, exams, x-rays and fluoride. Two times per plan year. Age 3 through deductible deductible
the end of the month in which the Member turns 19 years of age. Sealants once every
five years. See Master Policy for details.
Pediatric Vision Services 30% of In-Network Rate after 50% of In-Network Rate after
Lenses only. One time per plan year. Age 3 through the end of the month in which the deductible deductible
Member turns 19 years of age.
Can see Provider of choice
PROFESSIONAL SERVICES
PEHP e-Care Medical: $10 co-pay per visit after Not applicable
deductible
PEHP Value Clinics Medical: 30% after deductible Not applicable
Primary Care Visits | Includes office surgeries and inpatient visits 30% after deductible 40% after deductible
Specialist Visits | Includes office surgeries and inpatient visits 30% after deductible 40% after deductible
Surgery and Anesthesia 30% after deductible 40% after deductible
Emergency Room Specialist Visits 30% after deductible 30% after deductible
Diagnostic Tests, Labs, X-rays 30% after deductible 50% after deductible
Mental Health and Substance Abuse 30% after deductible 40% after deductible
No preauthorization required for outpatient service.
Inpatient services require preauthorization
*You pay 20% of the In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they
have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not count toward your deductible or out-of-pocket maximum.
**Payable only as secondary to a dental plan or if member does not have a separate dental plan.
WWW.PEHP.ORG WWW.PEHP.ORG
PAGE 21State
State of of Utah
Utah 2020-21
2020-21 » Consumer
» Consumer Plus
Plus » Benefits
Plan Grids
» Benefits Grids
In-Network Provider Out-of-Network Provider*
Balance billing may apply
PRESCRIPTION DRUGS | All pharmacy benefits for The STAR Plan are subject to the deductible. For Drug Tier info, see the Covered Drug List at www.pehp.org
30-day Pharmacy Preferred generic: Plan pays up to the discounted cost.
Retail only 30% of discounted cost Member pays any balance
Preferred brand name:
30% of discounted cost
Specialty Medications, office/outpatient 30% of In-Network Rate. Not covered
Up to 30-day supply No maximum Co-Insurance
Specialty Medications, through Home Health or Accredo 30% of In-Network Rate. Not covered
Up to 30-day supply No maximum Co-Insurance
OUTPATIENT FACILITY SERVICES
Outpatient Facility and Ambulatory Surgical Center 30% after deductible 50% after deductible
Urgent Care Facility 30% after deductible 50% after deductible
Emergency Room 30% after deductible 30% after deductible
Medical emergencies only, as determined by PEHP.
If admitted, inpatient facility benefit will be applied
Ambulance (ground or air) 30% after deductible
Medical emergencies only, as determined by PEHP
Diagnostic Tests, Labs, X-rays 30% after deductible 50% after deductible
Chemotherapy, Radiation, and Dialysis 30% after deductible 50% after deductible
Dialysis from out-of-network provider requires Preauthorization
Physical, Occupational and Speech Therapy 30% after deductible 50% after deductible
Outpatient – Up to 10 combined visits per plan year.
INPATIENT FACILITY SERVICES
Medical & Surgical 30% after deductible 50% after deductible
All out-of-network facilities and some in-network facilities require preathorization.
See Master Policy for details
Skilled Nursing Facility and Rehabilitation 30% after deductible 50% after deductible
Non-custodial. Up to 30 days per plan year. Requires preauthorization
Hospice 30% after deductible 50% after deductible
Mental Health & Substance Abuse 30% after deductible 50% after deductible
Requires Preauthorization
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WWW.PEHP.ORG
PAGEState
State of of Utah
Utah 2020-21
2020-21 » Consumer
» Consumer Plus
Plus » Benefits
Plan Grids
» Benefits Grids
In-Network Provider Out-of-Network Provider*
Balance billing may apply
MISCELLANEOUS SERVICES
Adoption | See Master Policy for benefit limits 30% after deductibe, up to $4,000 per adoption
Allergy Serum 30% after deductible 50% after deductible
Chiropractic care Not covered Not covered
Durable Medical Equipment 30% after deductible 50% after deductible
Some DME requires preauthorization. Visit www.pehp.org for complete list. Summit Network: Alpine Home Medical
See Master Policy for benefit limits
Medical Supplies 30% after deductible 50% after deductible
See Master Policy for benefit limits
Home Health/Skilled Nursing 30% after deductible 50% after deductible
Up to 30 visits per plan year
Injections 30% after deductible 50% after deductible
Includes allergy injections. See above for allergy serum
Infertility Services Not covered Not covered
Sleep Studies and Sleep Equipment Not covered Not covered
Temporomandibular Joint Dysfunction Not covered Not covered
WWW.PEHP.ORG 23
WWW.PEHP.ORG
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