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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesSalt Lake Community College HDHP Medical PlanCoverage Period: 07/01/2020 – 06/30/2021Coverage for: Individual and Eligible Family Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share thecost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only asummary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to regence.com or call 1 (866) 240-9580. For generaldefinitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You canview the Glossary at healthcare.gov/sbc-glossary or call 1 (866) 240-9580 to request a copy.Important QuestionsWhat is the overalldeductible?AnswersIn-network: 1,500 individual (single coverage) / 3,000 family per plan year.Out-of-network: 3,000 individual (singlecoverage) / 6,000 family per plan year.Why This Matters:Generally, you must pay all of the costs from providers up to the deductible amountbefore this plan begins to pay. If you have other family members on the policy, theoverall family deductible must be met before the plan begins to pay.Are there services coveredbefore you meet yourdeductible?Yes. Certain preventive care and those serviceslisted below as "deductible does not apply" or as"No charge."This plan covers some items and services even if you haven't yet met the deductibleamount. But a copayment or coinsurance may apply. For example, this plan coverscertain preventive services without cost sharing and before you meet your deductible.See a list of covered preventive services at re there other deductiblesfor specific services?No.You don't have to meet deductibles for specific services.What is the out-of-pocketlimit for this plan?What is not included in theout-of-pocket limit?In-network: 3,000 individual (single coverage) / 6,000 family per plan year.Out-of-network: 6,000 individual (singlecoverage) / 12,000 family per plan year.Premiums, balance-billed charges, and healthcare this plan doesn't cover.The out-of-pocket limit is the most you could pay in a year for covered services. If youhave other family members in this plan, the overall family out-of-pocket limit must bemet.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use anetwork provider?Yes. See regence.com/go/ or call 1(866) 240-9580 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan'snetwork. You will pay the most if you use an out-of-network provider, and you mightreceive a bill from a provider for the difference between the provider's charge andwhat your plan pays (balance billing). Be aware, your network provider might use anout-of-network provider for some services (such as lab work). Check with yourprovider before you get services.Do you need a referral to seea specialist?No.You can see the specialist you choose without a referral.1 of 6Claims Administrator: Regence BlueCross BlueShield of UtahUU0120SHH3X

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.Common MedicalEventServices You May NeedPrimary care visit to treatan injury or illnessIf you visit a healthcare provider's officeor clinicIf you have a testIf you need drugs totreat your illness orconditionMore information aboutprescription drugcoverage is available t ic test (x-ray,blood work)Imaging (CT/PET scans,MRIs)Preferred generic drugs &generic drugsPreferred brand drugsBrand drugsWhat You Will PayIn-network ProviderOut-of-network Provider(You will pay the least)(You will pay the most) 25 copay / office visit(including expandedservices);30% coinsurance10% coinsurance for allother services 35 copay / visit (includingexpanded services);10% coinsurance for allother services30% coinsuranceNo charge30% coinsurance10% coinsurance30% coinsurance10% coinsurance30% coinsuranceLimitations, Exceptions, & Other ImportantInformationCoverage includes primary care visits at a retail clinic.Copayment applies to each in-network office visit only,after deductible. All other services are covered at thecoinsurance specified, after deductible.Expanded services are medical services, surgicalprocedures and therapeutic injections received in aprofessional provider's office and billed as such. Allother services are covered at the coinsurancespecified, after deductible.You may have to pay for services that aren'tpreventive. Ask your provider if the services neededare preventive. Then check what your plan will pay for.None 7 copay / preferred retail prescription 7 copay / preferred mail order prescription 7 copay / retail prescription 7 copay / mail order prescription10% coinsurance for diabetic supplies.25% coinsurance up to 150 copay maximum / retailprescription25% coinsurance up to 300 copay maximum / mail orderprescription10% coinsurance for diabetic supplies30% coinsurance up to 175 copay maximum / retailprescription30% coinsurance up to 437.50 copay maximum / mailorder prescription10% coinsurance for diabetic suppliesCoverage includes compound medications, refer toyour plan for further information.Deductible does not apply for generic or preferredbrand drugs specifically designated as preventive fortreatment of certain chronic diseases that are on theOptimum Value Medication List.Limited to a 90-day supply retail (1 copayment per 30day supply), 90-day supply mail order or 30-day supplyspecialty drugs.No charge for certain preventive drugs, women'scontraceptives and immunizations at a participatingpharmacy.Specialty drugs (including preferred) are not availablethrough mail order.The first fill for designated specialty drugs may be2 of 6

Common MedicalEventServices You May NeedPreferred specialty drugs& specialty drugsIf you have outpatientsurgeryIf you need immediatemedical attentionIf you have a hospitalstayIf you need mentalhealth, behavioralhealth, or substanceabuse servicesIf you are pregnantWhat You Will PayIn-network ProviderOut-of-network Provider(You will pay the least)(You will pay the most)Limitations, Exceptions, & Other ImportantInformation10% coinsurance up to 250 copay maximum / preferredretail prescription15% coinsurance up to 300 copay maximum / retailprescriptionprovided at a retail pharmacy; additional fills and anyfills for other non-designated specialty drugs must beprovided by a specialty pharmacy.Medications used as part of an outpatient cancer drugtreatment regimen that is provided and dispensed in aprofessional setting will be subject to these prescriptionbenefits.Facility fee (e.g.,ambulatory surgerycenter)10% coinsurance30% coinsuranceNonePhysician/surgeon fees10% coinsurance30% coinsuranceNoneEmergency room services10% coinsurance10% coinsuranceNoneEmergency medicaltransportation10% coinsurance10% coinsuranceNoneUrgent care 35 copay / visit; otherservices 10% coinsurance30% coinsuranceCopayment applies to each in-network office visit only,after deductible. All other services are covered at thecoinsurance specified, after deductible.10% coinsurance30% coinsurance10% coinsurance 25 copay / visit; outpatientfacility services 10%coinsurance10% coinsurance10% coinsurance30% coinsurance30% coinsurance30% coinsurance10% coinsurance30% coinsuranceFacility fee (e.g., hospitalroom)Physician/surgeon feesOutpatient servicesInpatient servicesOffice visitsChildbirth/deliveryprofessional services30% coinsuranceNoneCopayment applies to each in-network office visit only,after deductible. All other services are covered at thecoinsurance specified, after deductible.Adoption coverage is paid at the in-network benefitlimited to 3,000 / pregnancy. The adoption indemnitybenefit is not exchangeable for infertility treatment3 of 6

Common MedicalEventIf you need helprecovering or haveother special healthneedsServices You May NeedWhat You Will PayIn-network ProviderOut-of-network Provider(You will pay the least)(You will pay the most)Childbirth/delivery facilityservices10% coinsurance30% coinsuranceHome health care10% coinsurance30% coinsuranceRehabilitation services10% coinsurance30% coinsuranceHabilitation services10% coinsurance30% coinsuranceLimitations, Exceptions, & Other ImportantInformationbenefits.Cost sharing does not apply for preventive servicesDepending on the type of services, copayment,coinsurance or deductible may apply. Maternity caremay include tests and services described elsewhere inthe SBC (i.e. ultrasound).NoneLimited to 60 inpatient days / year.Limited to 30 outpatient visits / year combined withoutpatient habilitation visit limit.Includes physical therapy, occupational therapy andspeech therapy services.Neurodevelopmental therapy is limited to 30 outpatientvisits / year combined with outpatient rehabilitation visitlimit.Neurodevelopmental therapy is limited to services forindividuals through age 18.Includes physical therapy, occupational therapy andspeech therapy services.Limited to 60 inpatient days / year.Skilled nursing care10% coinsurance30% coinsuranceDurable medical10% coinsurance30% coinsuranceNoneequipmentHospice services10% coinsurance30% coinsuranceNoneNot coveredNot coveredChildren's eye examNoneIf your child needsChildren's glassesNot coveredNot coveredNonedental or eye careChildren's dental checkNot coveredNot coveredNoneupExcluded Services & Other Covered Services:Exclusion ExamplesThe following examples of limitations and exclusions are included to illustrate the types of conditions, treatments, services, supplies or accommodations that may notbe covered under your plan, including related secondary medical conditions and are not all inclusive: charges in connection with reconstructive or plastic surgery that may have limited benefits, such as a chemical peel that does not alleviate a functionalimpairment; complications relating to services and supplies for, or in connection with, gastric or intestinal bypass, gastric stapling, or other similar surgical procedure tofacilitate weight loss, or for, or in connection with, reversal or revision of such procedures, or any direct complications or consequences thereof;4 of 6