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University of Utah Health Plans: Healthy Preferred EPOSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 8/1/2016 – 7/31/2016Coverage for: Hughes Companies Plan Type: EPOThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at www.uhealthplan.utah.edu/hughes-companies/ or by calling 1-888-271-5870.Important QuestionsAnswersWhy this Matters:What is the overalldeductible?For in-network providers: 1,000 Individual 2,000 Family of 2 or moreYou must pay all the costs up to the deductible amount before this plan begins to pay for coveredservices you use. Check your policy or plan document to see when the deductible starts over. Seethe chart starting on page 3 for how much you pay for covered services after you meet thedeductible.Are there otherdeductibles for specificservices?Is there an out–of–pocket limit on myexpenses?NoYou must pay all of the costs for these services up to the specific deductible amount before thisplan begins to pay for these servicesYes. For in-network providers: 3,500 Individual 7,000 Family of 2 or moreThe out-of-pocket limit is the most you could pay during a coverage period (usually one year) foryour share of the cost of covered services. This limit helps you plan for health care expenses.What is not included inthe out–of–pocketlimit?Premiums, balance-billed chargesand health care this plan doesn’tcover.Even though you pay for these expenses, they don’t count toward the out-of-pocket limit.Is there an overallannual limit on whatthe plan pays?No.The chart starting on page 3 describes any limits on what the plan will pay for specific coveredservices, such as office visits.Does this plan use anetwork of providers?Yes. For a list of in-networkproviders visitwww.uhealthplan.utah.edu or call1-888-271-5870.If you use an in-network doctor or other health care provider, this plan will pay some or all of thecosts of covered services. Be aware, your in-network doctor or hospital may use an out-of-networkprovider for some services. Plans use the term in-network, preferred, or participation forproviders in their network. See the chart starting on page 3 for how this plan pays different kindsof providers.Do I need a referral tosee a specialist?No.You can see the specialist you choose without permission from this plan.Are there services thisplan doesn’t cover?Yes.Some of the services this plan doesn’t cover are listed on pages 5. See your policy or plan documentfor additional information about excluded services.Questions: Call 1-888-271-5870 or visit us at www.uhealthplan.utah.edu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.uhealthplan.utah.edu or call 1-888-271-5870 to request a copy.1 of 9

University of Utah Health Plans: Healthy Preferred EPOSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 8/1/2016 – 7/31/2016Coverage for: Hughes Companies Plan Type: EPOOMB Control Numbers 1545-2229,1210-0147, and 0938-1146Corrected on May 11, 2012Questions: Call 1-888-271-5870 or visit us at www.uhealthplan.utah.edu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.uhealthplan.utah.edu or call 1-888-271-5870 to request a copy.2 of 9

University of Utah Health Plans: Healthy Preferred EPOSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 8/1/2016 – 7/31/2016Coverage for: Hughes Companies Plan Type: EPO Copayments are fixed dollar amounts (for example, 25) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, ifthe plan’s allowed amount for an overnight hospital stay is 1,000, your coinsurance payment of 20% would be 200. This may change ifyou haven’t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges 1,500 for an overnight stay andthe allowed amount is 1,000, you may have to pay the 500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.CommonMedical EventIf you visit a healthcare provider’s officeor clinicPrimary care visit to treat an injury or illnessSpecialist visitYour Cost IfYou Use anIn-networkProvider 25 Copay/visit 50 Copay/visitYour Cost IfYou Use anOut-of-networkProviderNot CoveredNot CoveredOther practitioner office visit 50 Copay/visitNot CoveredPreventive care/screening/immunizationNo ChargeNot CoveredServices You May NeedDiagnostic test (x-ray, blood work)If you have a testImaging (CT/PET scans, MRIs)Deductible, then20% coinsuranceDeductible, then20% coinsuranceLimitations & Exceptions---none-----none--Spinal manipulations are limited to 12per plan year.Refer to the plan document for acomplete list of preventative services.Not Covered---none---Not Covered---none---Questions: Call 1-888-271-5870 or visit us at www.uhealthplan.utah.edu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.uhealthplan.utah.edu or call 1-888-271-5870 to request a copy.3 of 9

University of Utah Health Plans: Healthy Preferred EPOSummary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventServices You May NeedPreventive DrugsYour Cost IfYou Use anIn-networkProviderNo ChargeCoverage Period: 8/1/2016 – 7/31/2016Coverage for: Hughes Companies Plan Type: EPOYour Cost IfYou Use anOut-of-networkProviderNot CoveredIf you need drugs totreat your illness orconditionPreferred generic drugs – 30 day supplyPreferred generic drugs – 90 day supply-Mail order 7 Copay 14 CopayNot CoveredMore informationabout prescriptiondrug coverage isavailable at referred brand drugs – 30 day supplyPreferred brand drugs – 90 day supply-Mail order 30 Copay 60 CopayNot CoveredNon-preferred brand drugs – 30 day supplyNon-preferred brand drugs – 90 day supply-Mail order35% Coinsurance35% CoinsuranceNot CoveredSpecialty drugs - Must use University of UtahSpecialty Pharmacy – 30 day supply only20% CoinsuranceNot CoveredIf you haveoutpatient surgeryIf you needimmediate medicalattentionFacility fee (e.g., ambulatory surgery center)Physician/surgeon feesEmergency room servicesEmergency medical transportationUrgent careDeductible, then20% CoinsuranceDeductible, then20% CoinsuranceLimitations & ExceptionsRefer to the drug formulary fordetailed information.Quantity Limits, Step Therapy, andPrior Authorization may apply. Referto the drug formulary for detailedinformation.Quantity Limits, Step Therapy, andPrior Authorization may apply. Referto the drug formulary for detailedinformation.Quantity Limits, Step Therapy, andPrior Authorization may apply. Referto the drug formulary for detailedinformation.Quantity Limits, Step Therapy, andPrior Authorization may apply. Referto the drug formulary for detailedinformation.Not Covered---none---Not Covered---none---Deductible, then 250 CopayDeductible, then 250 CopayCopayment is waived if admitteddirectly to a hospital or facility on aninpatient basis.Deductible, then20% Coinsurance 50 Copay/visitDeductible, then20% CoinsuranceNot CoveredQuestions: Call 1-888-271-5870 or visit us at www.uhealthplan.utah.edu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.uhealthplan.utah.edu or call 1-888-271-5870 to request a copy.Non-emergency use is not covered.---none--4 of 9

University of Utah Health Plans: Healthy Preferred EPOSummary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventIf you have ahospital stayIf you have mentalhealth, behavioralhealth, or substanceabuse needsIf you are pregnantIf you need helprecovering or haveother special healthneedsYour Cost IfYou Use anServices You May NeedIn-networkProviderDeductible, thenFacility fee (e.g., hospital room)20% CoinsuranceDeductible, thenPhysician/surgeon fee20% CoinsuranceMental/Behavioral health outpatient services 25 Copay/visitDeductible, thenMental/Behavioral health inpatient services20% CoinsuranceSubstance use disorder outpatient services 25 Copay/visitDeductible, thenSubstance use disorder inpatient services20% CoinsuranceDeductible, thenPrenatal and postnatal care20% CoinsuranceDeductible, thenDelivery and all inpatient services20% CoinsuranceDeductible, thenHome health care20% CoinsuranceCoverage Period: 8/1/2016 – 7/31/2016Coverage for: Hughes Companies Plan Type: EPOYour Cost IfYou Use anOut-of-networkProviderLimitations & ExceptionsNot Covered---none---Not Covered---none---Not Covered---none---Not Covered---none---Not Covered---none---Not Covered---none---Not Covered---none---Not Covered---none---Not CoveredRehabilitation servicesDeductible, then20% CoinsuranceNot CoveredHabilitation servicesDeductible, then20% CoinsuranceNot CoveredSkilled nursing careDurable medical equipmentHospice serviceEye examDeductible, then20% CoinsuranceDeductible, then20% CoinsuranceDeductible, then20% Coinsurance 25 CopayNot CoveredNot CoveredNot CoveredNot CoveredQuestions: Call 1-888-271-5870 or visit us at www.uhealthplan.utah.edu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.uhealthplan.utah.edu or call 1-888-271-5870 to request a copy.Limited to 60 visits per year. Priorauthorization is required.Limited to 40 visits per year total forboth rehabilitation and habilitationservices.Limited to 40 visits per year total forboth rehabilitation and habilitationservices.Limited to 60 days per year.Prior authorization is required fordurable medical equipment over 750.Limited to six months per lifetime.Prior authorization is required.One visit per plan year.5 of 9

University of Utah Health Plans: Healthy Preferred EPOSummary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventIf you need dental oreye careCoverage Period: 8/1/2016 – 7/31/2016Coverage for: Hughes Companies Plan Type: EPOGlassesYour Cost IfYou Use anIn-networkProviderNot CoveredYour Cost IfYou Use anOut-of-networkProviderNot CoveredDental check-upNot CoveredNot CoveredServices You May NeedLimitations & ExceptionsNot ApplicableNot ApplicableExcluded Services & Other Covered Services:Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Bariatric Surgery Private Duty Nursing Cosmetic Surgery Dental CareLong-term care Hearing aidsNon-emergency care when traveling outsidethe U.S. Weight loss programsOther Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.) Adoption services Mastectomy and breast reconstruction AutismYour Rights to Continue Coverage:Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There areexceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage areaQuestions: Call 1-888-271-5870 or visit us at www.uhealthplan.utah.edu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.uhealthplan.utah.edu or call 1-888-271-5870 to request a copy.6 of 9