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MEDICARE RETIREE GROUP PLANSREGENCE MEDADVANTAGE RX PRIMARY (PPO)REGENCE MEDADVANTAGE RX CLASSIC (PPO) W/COMP DENTAL2021 Summary of Benefitsfor Salt Lake Community College

The information listed is a summary of what we cover and what you pay. It does not list every service,coverage limitation or exclusion. A complete list of services we cover is found in our Evidence ofCoverage (EOC). Call 1-888-319-8904 (TTY: 711) to request a copy of the plan’s EOC.Regence MedAdvantage RxPrimary (PPO)Annual deductibleMedical 0Prescription 0 (Tiers 1,2) 200 (Tiers 3,4,5)Maximum out-of-pocket responsibility 5,900 in-network 10,000 combined in- and out-of-networkIn-networkOut-of-networkDays 1-4: 400 / dayDays 5 : 0 / dayDays 1 : 50%Ambulatory surgery center services1For wound care 4550%For all other services 30050%Outpatient hospital services¹For wound care 4550%For observation 9050%For all other services 35050%Doctor visitsPrimary care provider 550%Specialist 4550%Preventive care 050%Emergency care 90 90Urgently needed services 45 45Inpatient hospital coverage11- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.2 PPO

To join a Regence Medicare Advantage Retiree Group Plan, you must be entitled to MedicarePart A, be enrolled in Medicare Part B, be eligible for your employer’s retiree plan and live within theUnited States. As long as you are eligible for your employer’s retiree plan, you will have coverage inany state you live in (excluding U.S. territories). See other important plan information on page 12.Regence MedAdvantage RxClassic (PPO) w/Comp DentalWhat you should knowAmount you pay for health care services beforeyour health plan begins to pay. Deductibleamounts reset every calendar year on January 1. 0 0 (Tiers 1,2) 150 (Tiers 3,4,5) 5,500 in-network 10,000 combined in- and out-of-networkAnnual limit on your out-of-pocket costs for Part A(hospital) and Part B (medical) services. Does notinclude prescription drugs.In-networkOut-of-networkDays 1-4: 350 / dayDays 5 : 0 / dayDays 1 : 50% 4050% 22550% 4050% 9050% 30050% 050% 4050% 050%Cost-sharing may apply if you receive otherservices during your preventive care visit. 90 90Copay waived if admitted to the hospital within48 hours. 40 40There is no limit/maximum to number of days.1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.PPO 3

Regence MedAdvantage RxPrimary bs/imagingLab services1 0 - 2050%Outpatient X-rays 2050%Diagnostic tests and procedures1 2050%Diagnostic radiology (MRI, CT, etc.)120%50%Hearing servicesMedical hearing exam 4550%Routine hearing exam2 0 150Hearing aids (1 per ear, per year)2 699 or 999 per aidNot coveredDental servicesMedical dental services 4550%Preventive dental services2 050%Comprehensive dental services - diagnostic2 050%Comprehensive dental services - restorative2Not coveredNot coveredVision servicesMedical vision services 050%Routine vision exam2 050%Routine vision hardware2Lenses: 0Frames or contactlenses: 100 allowanceper yearLenses: 50%Frames or contactlenses: 100 allowanceper year1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.4 PPO

Regence MedAdvantage RxClassic (PPO) w/Comp DentalIn-networkOut-of-network 0 - 1050% 1050% 1050%20%50% 4050% 0 150 699 or 999 per aidNot covered 4050%What you should knowLower copay amount applies to HbA1C testing;higher copay applies to all other lab services.Routine hearing services provided by TruHearing for in-network coverage. Hearing aids coveredonly if obtained from TruHearing. 050%Covers preventive exams, bitewing X-rays,cleanings and topical fluoride two times percalendar year. Full-mouth X-rays covered onceevery three years. 050%Covers diagnostic exams and intraoral-periapicalX-rays two times per calendar year.50%; 1,000 benefitlimit per calendar year50%; 1,000 benefitlimit per calendar yearCovers crowns, dentures, partials, bridges,implants, restorations, endodontics, periodonticsand oral surgery. 050% 050%Lenses: 0Frames or contactlenses: 100 allowanceper yearLenses: 50%Frames or contactlenses: 100 allowanceper yearRoutine vision services provided by VSP VisionCare for in-network coverage. Covered lensesinclude basic single-vision, lined bifocal, linedtrifocal or lenticular lenses. One pair of lenses/frames or single purchase of contact lenses peryear.1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.PPO 5

Regence MedAdvantage RxPrimary (PPO)In-networkOut-of-networkDays 1-4: 400 / dayDays 1-190: 50%Mental health services1InpatientDays 5-190: 0 / dayOutpatient therapy (individual and group) 4050%Skilled nursing facility1Days 1-20: 0 / dayDays 1-100: 50%Days 21-100: 167 / dayPhysical therapy1 3050%Ambulance (air/ground)1 275 275TransportationNot coveredNot coveredMedicare Part B drugs120%50%Acupuncture (Medicare-covered) 2050%Chiropractic (Medicare-covered) 2050%Chiropractic (additional)2 2050%Annual physical exam 050%Fitness program (Silver&Fit )² 0Not coveredChronic health status 0Not coveredPost-discharge 0Not coveredAlternative careMeal delivery service21- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.6 PPO

Regence MedAdvantage RxClassic (PPO) w/Comp DentalIn-networkOut-of-networkDays 1-4: 350 / dayDays 1-190: 50%Days 5-190: 0 / day 4050%Days 1-20: 0 / dayDays 1-100: 50%Days 21-100: 160 / dayWhat you should knowThere is a 190-day lifetime maximum.Up to 100 days covered per benefit period. 2550%Includes occupational therapy and speechlanguage therapy. 275 275Copay applies for each one-way transport.Not coveredNot covered20%50% 2050% 2050%Limited to manipulation of the spine to correct asubluxation. 2050%Up to 18 visits (for Primary plan) or 24 visits (forClassic plan) per year. 050%In addition to the Medicare Annual Wellness Visit. 0Not coveredFitness center membership, home fitness optionsincluding a complimentary Fitbit, weekly healthcoaching and more. 0Not covered 0Not coveredUsually administered in a hospital setting, likechemotherapy drugs.Limited to treatment of chronic low back pain.Requires enrollment in care management program.Chronic health: 2 meals/day for 56 days, 112-meallimit.Post-discharge: 2 meals per day, 28 days, 56-meallimit.1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.PPO 7

Regence MedAdvantage RxPrimary (PPO)In-networkOut-of-networkPalliative care and support2 050%Personal emergency response system (PERS)2 0Not coveredMedicare-covered 4550%Diabetic routine foot care2 050%Virtual companionship2 0Not coveredVirtual visits (telehealth) 550%Podiatry services1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.8 PPO

Regence MedAdvantage RxClassic (PPO) w/Comp DentalIn-networkWhat you should knowOut-of-network 050%Includes care planning, pain/symptom managementand counseling services for patients, caregivers andfamilies in case of serious illness. 0Not coveredBenefit includes device and monthly monitoringservices. 4050% 050%Limit of 6 visits per year. 0Not coveredVirtual support services by phone. Limit of 4 visitsper month; up to 60 minutes per visit. 050%Medical and mental health services provided byMDLIVE or other provider by phone or video.1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.PPO 9

Prescription deductibleRegence MedAdvantage RxPrimary (PPO)Regence MedAdvantage RxClassic (PPO) w/Comp Dental 0 (Tiers 1,2) 200 (Tiers 3,4,5) 0 (Tiers 1,2) 150 (Tiers 3,4,5)Initial coverage (after deductible, what you pay until you and the plan pay 4,130 for prescription drugs)Tier 1: Preferred genericPreferred retailMail orderStandard retail1-month3-month1-month3-month 3 0 10 0 0 20 3 0 10 0 0 20 13 20 26 40 13 20 26 40 40 47 100 117.50 40 47 100 AN/ATier 2: GenericPreferred retail / mail orderStandard retailTier 3: Preferred brandPreferred retail / mail orderStandard retailTier 4: Non-preferred drugPreferred retail / mail orderStandard retailTier 5: SpecialtyPreferred retail / mail orderStandard retailCoverage gap (what you pay after you and your plan pay 4,130 for prescription drugs)Generic drugsYou pay 25%Brand-name drugsYou pay 25%Catastrophic coverage (what you pay after your total out-of-pocket costs reach 6,550)Generic drugsYou pay the greater of 3.70 or 5%Brand-name drugsYou pay the greater of 9.20 or 5%You may pay more than your copay or coinsurance amount if you get drugs from an out-of-networkpharmacy. Long-term care facility residents pay the same as at a standard retail pharmacy andare limited to a one-month supply (three-month supply is not available). Cost-sharing may changeif you qualify for Extra Help. To find out if you qualify, call the Social Security Administration at1-800-772-1213 (TTY: 1-800-325-0778) between 7 a.m. and 7 p.m., Monday through Friday.10 PPO

Prescription costs in the coverage gapDeductibleMeet your plan’s prescription deductibleYou first need to meet your plan’s annual prescriptiondeductible. Your deductible amount resets everycalendar year on Jan. 1. There is no deductible forgeneric medications on Tiers 1 and 2.Pay the plan’s prescriptiondeductible ( 0 for Tiers 1 and 2)Initial coveragePay a copay or coinsurance for each fill until totalspent by you and plan reaches 4,130After you meet your deductible, you pay a copay orcoinsurance for each prescription until the amountyou and your plan spend on prescriptions reachesthe initial coverage limit. Then you enter the coveragegap. Not everyone will enter the coverage gap.Pay a copay or coinsurance untilprescription costs reach 4,130Coverage gapPay 25% of negotiated price for generic andbrand-name drugs until your prescription spendingreaches 6,550After the initial coverage limit is met, you enterthe coverage gap. You pay 25% of your plan’snegotiated price for generic and brand-name drugsuntil your spending on prescription drugs reachesthe total out-of-pocket threshold. Then you entercatastrophic coverage.Pay 25% until your total spendon prescriptions reaches 6,550Catastrophic coveragePay the greater of 5% or 3.70 for generic drugs;pay the greater of 5% or 9.20 for brand-name drugsWhen you enter catastrophic coverage, you pay onlya small amount for your covered drugs for the rest ofthe year. Your plan pays the rest.Pay 5% or 3.70 for genericsand 5% or 9.20 for brandname drugsPPO 11