BENEFITS ENROLLMENT GUIDE JULY 1, JUNE 30, 2018

Transcription

1 BENEFITS ENROLLMENT GUIDE JULY 1, JUNE 30, 2018

2 Medical Benefits Administered by UMR All services are subject to the in-network contracted rates or out-of-network usual & customary rates. The Covered Person is responsible for all fees in excess of the usual & customary rates when using a Provider that does not participate on the UHC ChoicePlus, Options PPO, or one of the secondary networks. 001-Traditional Option Benefit Accumulator Contract Year Dependent Age Limit 26 Out-of-pocket Maximum (Per Person/Family Per Year - Separate from and not satisfied by the Prescription Drug Out-of-Pocket Maximum). $4,000 / $8,000 $5,500 / $11,000 * Includes Medical Deductible below. Medical Deductible (Per Person/Family Per Year - Separate from and not satisfied by the Prescription Drug Deductible). Please note. $750 / $1,500 $1,500 / $3,000 Non-Preauthorization Patient Penalty 50% reduction in benefits, limited to $1,000 penalty per incident PRESCRIPTION DRUG BENEFITS Prescription Drug Out-of-Pocket Maximum (Per Person/Family Per Year - Separate from and not satisfied by the Medical Out-of-Pocket $2,000 / $4,000 Maximum). Prescription Drug Deductible (Per Person/Family Per Year - Separate from and not satisfied by the Medical Deductible). Please note. $200 / $400 Participating R e t a i l Pharmacy (30 day supply) Generic - $4 Preferred - 30% Non-Preferred - 50% Mail Order or Costco Retail (90 day supply) Generic - $8 Preferred - 30% Non-Preferred - 50% Specialty Medications (30 day supply). Requires prior authorization. Must be acquired through Costco Specialty Services; first fill allowed at retail, but all 50% ($75 min; $250 max per script) other fills must be obtained through Costco Specialty Services. PREVENTIVE SERVICES Preventive Routine Exams, Screenings, Diagnostic Tests, Lab, and X-rays at Appropriate Ages and Gender (Typically 1 per year) Routine Well-Baby Exams Covered Immunizations (excludes immunizations required exclusively for foreign travel) Routine Vision Exam (1 visit per year) Routine Hearing Exam (1 visit per year) PHYSICIAN & PROFESSIONAL SERVICES Physician Office Visits (Primary Care) $30 40% Physician Office Visits (Secondary Care) $40 40% Physician Office Visits (After Hours) $40 40% Physician Visits (Inpatient & Outpatient) 20% 40% Advanced Imaging, CT Scan, PET Scans, MRI, MRA, Nuclear Medicine 20% 40% Basic Lab and X-ray (Office & Outpatient) 20% 40% Basic Lab and X-ray (Inpatient) 20% 40% Radiology/Pathology (Office & Outpatient) 20% 40% Radiology/Pathology (Inpatient) 20% 40% Surgery (Office) 20% 40% Surgery (Inpatient & Outpatient) 20% 40% Anesthesiology (Office) 20% 40% Anesthesiology (Inpatient & Outpatient) 20% 40% Routine Prenatal & Delivery (Dependent maternity included) $40 first visit only then 40% Home Health Care (in lieu of Hospital) (for supplies, see Medical Supplies and Equipment) 20% 40% Rehabilitation Therapy (Outpatient Physical, Speech, Occupational, Cardiac, or Pulmonary - 50 visits per year) $40 40% Manipulations (20 visits per person per Year) $40 50% 1

3 Medical Benefits Administered by UMR 001-Traditional Option Allergy Testing 20% 40% Allergy Serum/Injections $80 plan year deductible DENTAL BENEFITS Impacted Teeth/Cysts/Tumors 20% 40% HOSPITAL/FACILITY BENEFITS (Physician and Professional Services are not included in this section.) Medical/Surgical/Maternity/Intensive Care (Semi-Private Room) 20% 40% Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) 20% 40% Skilled Nursing Facility (60 day per Year) (Admission must be within 5 20% 40% days of discharge from Hospital Confinement) Medical/Surgical Care (Outpatient) 20% 40% Emergency Room (ER) $ % Coinsurance $ % Coinsurance Advanced Imaging, CT Scan, PET Scans, MRI, MRA, Nuclear Medicine 20% 40% Basic Lab & X-ray (Inpatient) 20% 40% Basic Lab & X-ray (Outpatient) 20% 40% Newborn 20% 40% InstaCare Clinic $40 40% Eligible Preventive Services REHABILITATION THERAPY BENEFIT Inpatient Physical, Speech, Occupational, Cardiac, or Pulmonary 20% 40% ACCIDENT AND LIFE THREATENING ILLNESS Medical/Surgical Physician/Facility/ER Covered as any other condition Ambulance Land/Air (Accident & Life-threatening) 20% Covered as a Participating Benefit subject Orthodontic Injury Treatment 20% to the Usual & Customary Rates Dental Injury Treatment 20% TRANSPLANT BENEFIT Heart, Liver, Pancreas, Bone Marrow, Cornea, Lung, Kidney, Small Bowel, Bone Marrow, Stem Cell Transplant Covered as any other condition MEDICAL SUPPLIES & EQUIPMENT Medical Supplies 20% 40% Medical Supplies (Office) 20% 40% Durable Medical Equipment 20% 40% Orthotic Supplies 20% MENTAL HEALTH & DRUG/ALCOHOL TREATMENT Inpatient Facility Semi-private Room 20% 40% Inpatient Facility Ancillary 20% 40% Inpatient Facility Physician Visits 20% 40% Office Visits $30 40% ADDITIONAL BENEFITS Adoption Indemnity Benefit The Plan pays a maximum $4,000 towards adoption expenses per child TMJ Syndrome diagnosis & non-surgical treatment 50% Orthognathic/Mandibular Osteotomy ($2,500 per occurrence) 50% Total Parenteral Nutrition (TPN) 20% 50% Infertility Treatment 50% EMPLOYEE ASSISTANCE PROGRAM (EAP) OptumHealth EAP ( access code: UVU) Unlimited confidential telephonic sessions; 24-hour member portal; and Up to five (5) in-person EAP visits per year at no cost to you PLEASE NOTE: This summary is for illustrative purposes only and does not guarantee benefits. All benefits are subject to the terms, limitations, and exclusions set forth in the Plan document and in the Summary Plan Description (SPD)/handbook of the Plan. Any discrepancies between this summary, the SPD/handbook, and the Plan document are resolved in favor of the Plan document. Prior authorizations may be required before benefits will be considered for payment. For a description of these services and prior authorization procedures, refer to the SPD/ handbook or the Plan document, or contact the UMR Customer Service Department. Services designated are subject to first dollar Medical Deductible. Services designated are subject to first dollar Prescription Deductible. 2

4 Administered by UMR All services are subject to the in-network contracted rates or out-of-network usual & customary rates. The Covered Person is responsible for all fees in excess of the usual & customary rates when using a Provider that does not participate on the UHC ChoicePlus, Options PPO, or one of the secondary networks. 003, 004-HDHP Option Benefit Accumulator Contract Year Dependent Age Limit 26 Out-of-pocket Maximum (Single coverage only/family coverage only) *Includes Medical Deductible below. $3,000 / $6,000 $6,000 / $12,000 Medical Deductible (Single coverage only/family coverage only) Services subject to the deductible. $2,000 / $4,000 $4,000 / $8,000 Non-Preauthorization Patient Penalty 50% reduction in benefits, limited to $1,000 penalty per incident PRESCRIPTION DRUG BENEFITS Participating Retail Pharmacy (30 day supply) Generic - $4 after deductible Preferred - 30% after deductible Non-Preferred - 50% after deductible Mail Order or Costco Retail (90 day supply) Generic - $8 after deductible Preferred - 30% after deductible Non-Preferred - 50% after deductible Specialty Medications (30 day supply). Requires prior authorization. Must be acquired through Costco Specialty Services; first fill allowed at retail, but all 50% ($75 min; $250 max per script) other fills must be obtained through Costco Specialty Services. PREVENTIVE SERVICES Preventive Routine Exams, Screenings, Diagnostic Tests, Lab, and X-rays at Appropriate Ages and Gender (Typically 1 per year) Routine Well-Baby Exams Covered Immunizations (excludes immunizations required exclusively for foreign travel) Routine Vision Exam (1 visit per year) Routine Hearing Exam (1 visit per year) PHYSICIAN & PROFESSIONAL SERVICES Physician Office Visits (Primary Care) $25 after deductible 40% Physician Office Visits (Secondary Care) $35 after deductible 40% Physician Office Visits (After Hours) $35 after deductible 40% Physician Visits (Inpatient & Outpatient) 20% after deductible 40% Advanced Imaging, CT Scan, PET Scans, MRI, MRA, Nuclear Medicine 20% after deductible 40% Basic Lab and X-ray (Office & Outpatient) 20% after deductible 40% Basic Lab and X-ray (Inpatient) 20% after deductible 40% Radiology/Pathology (Office & Outpatient) 20% after deductible 40% Radiology/Pathology (Inpatient) 20% after deductible 40% Surgery (Office) 20% after deductible 40% Surgery (Inpatient & Outpatient) 20% after deductible 40% Anesthesiology (Office) 20% after deductible 40% Anesthesiology (Inpatient & Outpatient) 20% after deductible 40% Routine Prenatal Preventive (Dependent maternity included) 40% Other Prenatal, Delivery, Postnatal 20% after deductible 40% Home Health Care (in lieu of Hospital) (for supplies, see Medical Supplies and Equipment) 20% after deductible 40% Rehabilitation Therapy (Outpatient Physical, Speech, Occupational, Cardiac, or Pulmonary - 50 visits per year) $35 after deductible 40% Manipulations (20 visits per person per year) $35 after deductible 50% Allergy Testing 20% after deductible 40% Allergy Serum/Injections 20% after deductible DENTAL BENEFITS Impacted Teeth/Cysts/Tumors 20% after deductible 40% 1

5 Administered by UMR 003, 004-HDHP Option HOSPITAL/FACILITY BENEFITS (Physician and Professional Services are not included in this section.) Medical/Surgical/Maternity/Intensive Care (Semi-Private Room) 20% after deductible 40% Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) 20% after deductible 40% Skilled Nursing Facility (60 day per year) (Admission must be within 5 days 20% after deductible 40% of discharge from Hospital Confinement) Medical/Surgical Care (Outpatient) 20% after deductible 40% Emergency Room (ER) $ % Coinsurance after deductible $ % Coinsurance after deductible Advanced Imaging, CT Scan, PET Scans, MRI, MRA, Nuclear Medicine 20% after deductible 40% Basic Lab & X-ray (Inpatient) 20% after deductible 40% Basic Lab & X-ray (Outpatient) 20% after deductible 40% Newborn 20% after deductible 40% InstaCare Clinic $35 after deductible 40% Eligible Preventive Services REHABILITATION THERAPY BENEFIT Inpatient Physical, Speech, Occupational, Cardiac, or Pulmonary 20% after deductible 40% ACCIDENT AND LIFE THREATENING ILLNESS Medical/Surgical Physician/Facility/ER Covered as any other condition Ambulance Land/Air (Accident & Life-threatening) 20% after deductible Covered as a Participating Benefit Orthodontic Injury Treatment 20% after deductible subject to the Usual & Customary Rates Dental Injury Treatment 20% after deductible TRANSPLANT BENEFIT Heart, Liver, Pancreas, Bone Marrow, Cornea, Lung, Kidney, Small Bowel, Bone Marrow, Stem Cell Transplant Covered as any other condition MEDICAL SUPPLIES & EQUIPMENT Medical Supplies 20% after deductible 40% Medical Supplies (Office) 20% after deductible 40% Durable Medical Equipment 20% after deductible 40% Orthotic Supplies 20% after deductible MENTAL HEALTH & DRUG/ALCOHOL TREATMENT Inpatient Facility Semi-Private Room 20% after deductible 40% Inpatient Facility Ancillary 20% after deductible 40% Inpatient Facility Physician Visits 20% after deductible 40% Office Visits $25 after deductible 40% ADDITIONAL BENEFITS Adoption Indemnity Benefit The Plan pays a maximum $4,000 towards adoption expenses per child TMJ Syndrome diagnosis & non-surgical treatment 50% after deductible Orthognathic/Mandibular Osteotomy ($2,500 per occurrence) 50% after deductible Total Parenteral Nutrition (TPN) 20% after deductible 50% Infertility Treatment 50% after deductible EMPLOYEE ASSISTANCE PROGRAM (EAP) OptumHealth EAP ( access code: UVU) Unlimited confidential telephonic sessions; 24-hour member portal; and Up to five (5) in-person EAP visits per year at no cost to you PLEASE NOTE: This summary is for illustrative purposes only and does not guarantee benefits. All benefits are subject to the terms, limitations, and exclusions set forth in the Plan document and in the Summary Plan Description (SPD)/handbook of the Plan. Any discrepancies between this summary, the SPD/handbook, and the Plan document are resolved in favor of the Plan document. Prior authorizations may be required before benefits will be considered for payment. For a description of these services and prior authorization procedures, refer to the SPD/ handbook or the Plan document, or contact the UMR Customer Service Department. Services designated are subject to first dollar Medical Deductible. 2

6 UVU 852 East Arrowhead Lane 800 West University Parkway Murray, Utah Orem, Utah (801) / (800) (801) Fax (801) Group: Plan: Administered by: Plan Type: Effective Date: Benefit Year: UTAH VALLEY UNIVERSITY - (Plan #128) Premier Indemnity Educators Mutual Insurance Association Contributory / Self Funded 7/1/2017 Contract Type 1 - Preventive Oral Exams, Cleanings, X-rays, Fluoride Type 2 - Basic Fillings, Oral Surgery Type 3 - Major Crowns, Bridges, Prosthodontics, Implants Type 4 - Orthodontics Dependent children up to age (26) 100% 100% 80% 80% 60% 60% 50% 50% Adults 50% 50% Orthodontic Discount (All Members) 25% Discount No Discount Endodontics Type 2 - Basic Type 2 - Basic Periodontics Type 2 - Basic Type 2 - Basic Sealants Type 2 - Basic Type 2 - Basic Space Maintainers Type 2 - Basic Type 2 - Basic Specialists Paid same as General Dentists Paid same as General Dentists Waiting periods Type 2 - Basic Type 3 - Major Type 4 - Orthodontics None 12 Month Late Entrant Waiting Period Deductible Per Person $50.00 $50.00 Family Max $ $ Deductible Applies To Type 2 & Type 3 Type 2 & Type 3 Annual Maximum Per Person $1, Orthodontic Lifetime Maximum $1, Network / Reimbursement Schedule Premier R&C (80th) Provisions / Limitations / Exclusions Exams (including Periodontal), Cleanings and Fluoride 2 per year Fluoride Up to age 16 Sealants Up to age 16 Space Maintainers Up to age 16 Bitewing X-Rays Up to 4, twice per year Periapical X-Rays 6 per year Panoramic X-Ray 1 every 3 years Impacted Teeth Covered in Type 2 - Basic Anesthesia- (Age 8 and over for the extraction of impacted teeth only) Anesthesia - (For children age 7 and under, once per year) Implants Crowns, Pontics, Abutments, Onlays and Dentures 1 every 5 years per tooth Fillings on the same surface 1 every 18 months Benefits illustrated are in summary only. Refer to your Dental Handbook for a complete description of benefits, limitations and exclusions. All Services are subject to Educators Mutual Table of Allowances. When using a Non-participating Provider, the insured is responsible for all fees in excess of the Table of Allowances. EM.DTL.PREM.CHT.B

7 Internal Dual Coverage Options The following is an additional medical and dental plan option for individuals where both spouses are employed by UVU. This plan is designed to provide more efficiency in claims processing for UVU employees and spouses who both work in a benefit eligible positions and are accustom to being double covered by a UVU health plan. The IDC plan is not compatible with a Health Savings Account and participation in this plan is optional. If you do not wish to participate in the IDC plan, but elect to enroll in the High Deductible or Traditional plan, the claims processing will not be coordinated.

8 Medical Benefits Administered by UMR All services are subject to the in-network contracted rates or out-of-network usual & customary rates. The Covered Person is responsible for all fees in excess of the usual & customary rates when using a Provider that does not participate on the UHC ChoicePlus, Options PPO, or one of the secondary networks. Internal Dual Coverage Option Benefit Accumulator Contract Year Dependent Age Limit 26 Out-of-pocket Maximum (Per Person/Family Per Year - Separate from and not satisfied by the Prescription Drug Out-of-Pocket Maximum). $2,000 / $4,000 $5,500 / $11,000 * Includes Medical Deductible below. Medical Deductible (Per Person/Family Per Year - Separate from and not satisfied by the Prescription Drug Deductible). Please note. $375 / $750 $1,500 / $3,000 Non-Preauthorization Patient Penalty 50% reduction in benefits, limited to $1,000 penalty per incident PRESCRIPTION DRUG BENEFITS Prescription Drug Out-of-Pocket Maximum (Per Person/Family Per Year - Separate from and not satisfied by the Medical Out-of-Pocket $1,000 / $2,000 Maximum). Prescription Drug Deductible (Per Person/Family Per Year - Separate from and not satisfied by the Medical Deductible). Please note. $100 / $200 Participating R e t a i l Pharmacy (30 day supply) Generic - $2 Preferred - 30% Non-Preferred - 50% Mail Order or Costco Retail (90 day supply) Generic - $4 Preferred - 30% Non-Preferred - 50% Specialty Medications (30 day supply). Requires prior authorization. Must be 50% ($37.50 min; $125 acquired through Costco Specialty Services; first fill allowed at retail, but all other fills must be obtained through Costco Specialty Services. max per script) PREVENTIVE SERVICES Preventive Routine Exams, Screenings, Diagnostic Tests, Lab, and X-rays at Appropriate Ages and Gender (Typically 1 per year) Routine Well-Baby Exams Covered Immunizations (excludes immunizations required exclusively for foreign travel) Routine Vision Exam (1 visit per year) Routine Hearing Exam (1 visit per year) PHYSICIAN & PROFESSIONAL SERVICES Physician Office Visits (Primary Care) $15 40% Physician Office Visits (Secondary Care) $20 40% Physician Office Visits (After Hours) $20 40% Physician Visits (Inpatient & Outpatient) 20% 40% Advanced Imaging, CT Scan, PET Scans, MRI, MRA, Nuclear Medicine 20% 40% Basic Lab and X-ray (Office & Outpatient) 20% 40% Basic Lab and X-ray (Inpatient) 20% 40% Radiology/Pathology (Office & Outpatient) 20% 40% Radiology/Pathology (Inpatient) 20% 40% Surgery (Office) 20% 40% Surgery (Inpatient & Outpatient) 20% 40% Anesthesiology (Office) 20% 40% Anesthesiology (Inpatient & Outpatient) 20% 40% Routine Prenatal & Delivery (Dependent maternity included) $20 first visit only then 40% Home Health Care (in lieu of Hospital) (for supplies, see Medical Supplies and Equipment) 20% 40% Rehabilitation Therapy (Outpatient Physical, Speech, Occupational, Cardiac, or Pulmonary - 50 visits per year) $20 40% Manipulations (20 visits per person per year) $20 50% 1

9 Medical Benefits Administered by UMR Internal Dual Coverage Option Allergy Testing 20% 40% Allergy Serum/Injections $40 plan year deductible DENTAL BENEFITS Impacted Teeth/Cysts/Tumors 20% 40% HOSPITAL/FACILITY BENEFITS (Physician and Professional Services are not included in this section.) Medical/Surgical/Maternity/Intensive Care (Semi-Private Room) 20% 40% Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) 20% 40% Skilled Nursing Facility (60 day per year) (Admission must be within 5 20% 40% days of discharge from Hospital Confinement) Medical/Surgical Care (Outpatient) 20% 40% Emergency Room (ER) $ % Coinsurance $ % Coinsurance Advanced Imaging, CT Scan, PET Scans, MRI, MRA, Nuclear Medicine 20% 40% Basic Lab & X-ray (Inpatient) 20% 40% Basic Lab & X-ray (Outpatient) 20% 40% Newborn 20% 40% InstaCare Clinic $20 40% Eligible Preventive Services REHABILITATION THERAPY BENEFIT Inpatient Physical, Speech, Occupational, Cardiac, or Pulmonary 20% 40% ACCIDENT AND LIFE THREATENING ILLNESS Medical/Surgical Physician/Facility/ER Covered as any other condition Ambulance Land/Air (Accident & Life-threatening) 20% Covered as a Participating Benefit subject to Orthodontic Injury Treatment 20% the Usual & Customary Rates Dental Injury Treatment 20% TRANSPLANT BENEFIT Heart, Liver, Pancreas, Bone Marrow, Cornea, Lung, Kidney, Small Bowel, Bone Marrow, Stem Cell Transplant Covered as any other condition MEDICAL SUPPLIES & EQUIPMENT Medical Supplies 20% 40% Medical Supplies (Office) 20% 40% Durable Medical Equipment 20% 40% Orthotic Supplies 20% MENTAL HEALTH & DRUG/ALCOHOL TREATMENT Inpatient Facility Semi-private Room 20% 40% Inpatient Facility Ancillary 20% 40% Inpatient Facility Physician Visits 20% 40% Office Visits $15 40% ADDITIONAL BENEFITS Adoption Indemnity Benefit The Plan pays a maximum $4,000 towards adoption expenses per child TMJ Syndrome diagnosis & non-surgical treatment 50% Orthognathic/Mandibular Osteotomy ($2,500 per occurrence) 50% Total Parenteral Nutrition (TPN) 20% 50% Infertility Treatment 50% EMPLOYEE ASSISTANCE PROGRAM (EAP) OptumHealth EAP ( access code: UVU) Unlimited confidential telephonic sessions; 24-hour member portal; and Up to five (5) in-person EAP visits per year at no cost to you PLEASE NOTE: This summary is for illustrative purposes only and does not guarantee benefits. All benefits are subject to the terms, limitations, and exclusions set forth in the Plan document and in the Summary Plan Description (SPD)/handbook of the Plan. Any discrepancies between this summary, the SPD/handbook, and the Plan document are resolved in favor of the Plan document. Prior authorizations may be required before benefits will be considered for payment. For a description of these services and prior authorization procedures, refer to the SPD/ handbook or the Plan document, or contact the UMR Customer Service Department Services designated are subject to first dollar Medical Deductible. Services designated are subject to first dollar Prescription Deductible. 2

10 UVU 852 East Arrowhead Lane 800 West University Parkway Murray, Utah Orem, Utah (801) / (800) (801) Fax (801) Group: Plan: Administered by: Plan Type: Effective Date: Benefit Year: UTAH VALLEY UNIVERSITY - (Plan #128) Premier Indemnity Internal Dual Plan Educators Mutual Insurance Association Contributory / Self Funded 7/1/2017 Contract Type 1 - Preventive Oral Exams, Cleanings, X-rays, Fluoride Type 2 - Basic Fillings, Oral Surgery Type 3 - Major Crowns, Bridges, Prosthodontics, Implants Type 4 - Orthodontics Dependent children up to age (19) 100% 100% 100% 80% 100% 60% 100% 50% Adults 100% 50% Orthodontic Discount (All Members)* 25% Discount No Discount Endodontics Type 2 - Basic Type 2 - Basic Periodontics Type 2 - Basic Type 2 - Basic Sealants Type 2 - Basic Type 2 - Basic Space Maintainers Type 2 - Basic Type 2 - Basic Specialists Paid same as General Dentists Paid same as General Dentists Waiting periods Type 2 - Basic Type 3 - Major Type 4 - Orthodontics None 12 Month Late Entrant Waiting Period Deductible In and Out of Network Deductibles are Combined Per Person $25.00 $50.00 Family Max $75.00 $ Deductible Applies To Type 2 & Type 3 Type 2 & Type 3 Annual Maximum Per Person $3, $1, Orthodontic Lifetime Maximum $3, $1, (All Maximums are combined up to the limits above) Network / Reimbursement Schedule Premier R & C (80th) Provisions / Limitations / Exclusions Exams (including Periodontal), Cleanings and Fluoride 2 per year Fluoride Up to age 16 Sealants Up to age 16 Space Maintainers Up to age 16 Bitewing X-Rays Up to 4, twice per year Periapical X-Rays 6 per year Panoramic X-Ray 1 every 3 years Impacted Teeth Covered in Type 2 - Basic Anesthesia- (Age 8 and over for the extraction of impacted teeth only) Anesthesia - (For children age 7 and under, once per year) Implants Crowns, Pontics, Abutments, Onlays and Dentures 1 every 5 years per tooth Fillings on the same surface 1 every 18 months Benefits illustrated are in summary only. Refer to your Dental Handbook for a complete description of benefits, limitations and exclusions. All Services are subject to EMI Health Table of Allowances. When using a Non-participating Provider, the insured is responsible for all fees in excess of the Table of Allowances. * The discount shown is for participating orthodontists in Utah. Discounts may vary outside of Utah. Administered by Educators Health Plans Life, Accident & Health

11 SUMMARY OF BENEFITS MONTHLY PREMIUMS FOR FULL-TIME BENEFIT-ELIGIBLE EMPLOYEES (Divide rates by two for per paycheck amounts) coverage may include employee, spouse, and dependent children to age 26. Choice Plus Network Options PPO Network Traditional Single Two-Party Family Single Two-Party Family Employee Premium $51.86 $ $ $83.96 $ $ University Contribution $ $ $ $ $ $ Internal Dual Coverage Single Two-Party Family Single Two-Party Family Employee Premium - $ $ $ $ University Contribution - $ $ $ $ High Deductible Single Two-Party Family Single Two-Party Family Employee Premium $0.00 $0.00 $0.00 $22.48 $51.92 $75.00 University Contribution $ $ $ $ $ $ Traditional Dental Internal Dual Dental Dental Single Two-Party Family Single Two-Party Family Employee Premium $12.48 $15.96 $ $28.44 $35.70 University Contribution $49.94 $63.86 $ $ $ Health Insurance summary tables and summary plan descriptions are available in the Benefits Service Center of myuvu or in the HR Benefits Office, BA 111. Wellness & Employee Assistance/Work-life Programs o UVUFit Employee Wellness Program health coaching, weight management and fitness, assessments, tips, trackers and other tools. o EAP/Work-Life Resources confidential therapy sessions, 24-hour crisis support, legal and financial consultations, child care and elderly care assistance, monthly on-line seminars and many more services to help you balance your life. Retirement- Employer-provided retirement plans. o Full-time employees receive a 100% UVU paid retirement plan, with no waiting period. UVU will contribute for all benefit-eligible employees to a 401(a) Defined Contribution Plan with a contribution rate of 14.2% (base salary). Investment options through TIAA or Fidelity Investments or both. o New benefit-eligible employees who have participated in Utah Retirement Systems (URS) in the past and wish to remain in URS may do so. Please contact HR Benefits Office for information. Supplemental Retirement Investment Options 403b, 401k, and 457b tax-deferred plans and Roth 403(b) and IRA plans are available through payroll deduction, no employer match. Life Insurance The University provides $50,000 term life and AD&D insurance policies for all benefit-eligible employees. Optional $5,000 dependent life is available for spouse and children, $1.40 a month, paid by employee. Supplemental term life and AD&D insurance is also available. Long-Term Disability Insurance (LTD) The University provides a LTD Insurance Plan. The plan covers benefiteligible employees that are unable to work in their current position, after a 5 month waiting period, at 66.67% of their base salary. Flexible Spending Account (FSA) Allows benefit-eligible employees to elect an amount to be deducted each payroll (before taxes) to pay for medical, dental, and vision expenses (portion not covered by insurances) tax free. No administrative fee for standard reimbursement. Health Savings Account Allows for a pre-tax, employee and employer contribution into a savings account for employees covered under a UVU HDHP. Monies can be used tax free for medical, dental, and vision expenses. Workers Compensation Insurance All employees are covered under the University s Workers Compensation Insurance policy for injuries or illnesses received as a result of their employment. UVU Tuition and Fees o Benefit-eligible employees Resident tuition and student fees are waived (up to 18 credits per semester/term) o Spouse and dependents of benefit-eligible employees Resident tuition only is waived (up to 18 credits per semester/term) o Does not cover graduate courses. Supplemental Insurance Options Additional insurances are available through payroll deduction. Premiums are paid by the employee. o Supplemental Life - term life and group accident plans are underwritten by Minnesota Life. o AFLAC - cancer and hospital intensive care. o MetLife Auto and Home - available through MetLife. o Supplemental Vision - available through United Healthcare. o Legal Plan available through Hyatt Legal Plans. More information can be found by logging into the Benefits Service Center of myuvu