2019 Temporary Employee Benefits Package Medical Insurance … benefits... · 2019 Temporary...

401k Retirement SavingsThis benefit is a retirement savings plan employees can contribute to via payroll

deductions. To be eligible for this benefit, employees need to have worked for

Jacobson on assignment for one year and 1000 hours. Email

[email protected] with any questions.

2019 Temporary Employee Benefits Package

Medical Insurance Options

• Talltree Administrators – Third Party Administrator www.talltreehealth.com (877) 453-4201• Optum RX – Pharmacy Benefit Manager (PBM) | www.optumrx.com• Sherppa – Telemedicine | www.sherpaa.com• Focus Health Solutions – Insurance Carrier• Multiplan’s PHCS Network – Provider, Hospital and Facility Network www.multiplan.com

Other Benefit Options

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) All MEC and MEC Plus Services $7,150 (individual) deductible Emergency Room and Inpatient Hospital Services (no day cap) Primary Care and Specialist visits Imaging, Laboratory Services, X-Rays and Diagnostic Imaging Certain Generic and Preferred Brand drugs TeleMed

Basic Preventativeand Wellness,Primary Care andSpecialist OfficeVisits (10 EachPer Year) Urgent Care

(3 Per Year) Basic Diagnostic

Services Inpatient Services

with Annual DayCap (NoDeductable) Outpatient Services

with Annual VisitCap (NoDeductable) Allergy Services and Home Health Care Perscriptions and TeleMed

All MEC PlusServices WithNo Office Visitor Urgent CareLimit Specialist

Office Visits(Exam orConsultation) Basic and Major

DiagnosticServices Emergency Room

(2 Per Year) Perscriptions and

TeleMed

Basic Preventativeand Wellness Primary Care

Office Visits (3 Per Year) Discount on

Specialist OfficeVisits, DiagnosticServices, andEmergency Room Urgent Care

(1 Per Year) Prescription

Drug Benefit TeleMed

http://www.talltreehealth.com/

https://www.optumrx.com/

https://sherpaa.com/

http://www.multiplan.com/

Jacobson Benefit Timeline

2019 Benefit Deduction Schedule Deductions are taken once a month as follows:

Helpful Hints • You will need to provide the birthday(s) and social security number(s)

for your spouse/dependents at the time of enrollment.• If you end an assignment with Jacobson and begin a new assignment

within 13 weeks, you will be automatically enrolled in your previousbenefit selections.

• If you have any questions, please email [email protected] call (800) 466-1578 and ask for HR.

• You will recieve a link from Employee Navigator with instructions on how to register

Your first week on assignment

• You must accept, upgrade, or waive benefits

Within 30 days of your hire date

• Benefits are prepaid monthly. Deductions begin on the last paycheck before your benefiteffective date

Last week of the month before your effective date

• This is your benefit effective date. You will recieve benefit enrollment materials in the mailto the address provided to Jacobson.

First of the month following sixty days of employment

• This is the last day your benefits will be in effect.

The last day of the month of termination/assignment completion

Paycheck Date Pays For Benefits In December 27, 2018 January

January 31, 2019 February February 27, 2019 March March 28, 2019 April April 25, 2019 May May 30, 2019 June June 27, 2019 July July 25, 2019 August

August 29, 2019 September September 26, 2019 October October 31, 2019 November

November 28, 2019 December

mailto:[email protected]

2019 Benefit Costs All listed rates are monthly. Deductions are made on the last paycheck of the month to

prepay for the following month’s coverage.

MEC Plus Employee Only $106.00 per month

Employee + Spouse $161.00 per month Employee + Children $172.00 per month

Family $249.00 per month

MEC Enhanced Employee Only $184.00 per month



Limited Day Medical Employee Only $298.00 per month



MVP * Employee Only $398.00 per month


Family $1,115.00 per month *Full time employees making less than $31.00 per hour may qualify for an employer subsidy for the MVP plan.

Applicable to employees making less than $31.00 per hour. Employees making more the $31.00 per hour will be responsible for the full cost of the plan.*

We hope you find our online enrollment tool simple and easy to use. We’ve broken the process down into five basic steps:

1. Receive your registration link2. Register3. Learn about your benefits and review your required tasks4. Enter personal information, select your enrollees and select your benefits5. Confirm your coverage and logout

Step 1: Receive your registration link

Within a week after your hire date you will receive a welcome email from [email protected] with a registration link and instructions.

Step 2: Register

You will need to create a username, password and confirm the last 4 of your Social Security Number. Use your personal email address as your username. The Company Identifier is “jacobson”.

Benefit Enrollment Instructions via EmployeeNavigator.com

Tasks

Benefit Information

Step 3: Learn about your benefits and review your required tasks

• Learn About Your Benefits:o Under the “Compliance Documents” header you will see a link that directs you to a

summary of each benefit.

• Review Your Required Taskso Click the “go” button next to review the company’s Minimum Essential Coverage

Policy

Step 4: Enter personal information, select enrollees and select benefits

You must have your spouse/dependents’ social security number(s) and birthday(s) to enroll.

1) Click Start Benefits link to begin2) Add dependents3) Select enrollees4) Choose benefit5) When enrolling spouse/dependents, be sure the circle next to their names are checked.6) Click “save and continue” or “don’t want this benefit” to decline.

Questions? Email [email protected] or call 800-466-1578 and ask for Human Resources.

Step 5: Confirm your coverage

Once you have gone through the benefit election process, a confirmation screen will appear showing you the benefits you elected and the cost that will be deducted from your paycheck each month (not a weekly deduction). Click “Agree” to confirm and finish.

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$28.07

mailto:[email protected]

2019Benefit Enrollment Guide

ENROLLMENT

You can enroll during your employer’s open enrollment period, during your new hire window or during a qualifying event.

If you are a new hire YOU MUST complete the enrollment process within 30 days from your hire date.

You can only make changes to your enrollment if you experience a qualifying event. A qualifying event is defined as a change in your status due to one of the following: marriage, divorce, birth or adoption, termination, loss of dependent and loss of prior coverage.

1)

2)

3)

IT IS OUR COMPANY POLICY THAT ALL EMPLOYEES COMPLETE THE ENROLLMENT PROCESS.

TO ENROLL?

Our 2019 health insurance offering aims at providing multiple benefit options for you and your family. Each plan delivers different levels of benefits designed to give you various coverage options corresponding to the respective premium.

All preventative mandated services

Primary Care office visits

Urgent Care

Telemedicine

Same as MEC Plus

Diagnostic Services(Basic and Major)

Emergency Room Benefit

Primary Care & Specialists

Inpatient and OutpatientHospital Benefit

Maternity Benefit

And More!

To remain compliant under the Healthcare Reform Employer Mandate, we offer twoMinimum Essential Coverage Plans (MEC’s) and a Limited Day Medical Plan. OurLimited Day Medical Plan is designed to give you the best possible benefits for thepremium. Additionally, a high dollar deductible Minimum Value Plan is beingoffered to further comply with the Affordable Care Act.

You may enroll during open enrollment, your new hire window or upon a qualifying event.

Understanding Your 2019 Health Insurance Options

BENEFIT

Please refer to the schedule of benefits on the next page.

Employee Only

Employee + Spouse

Employee + Child(ren)

Employee + Family

MonthlyPremium

MEC Plus

Employee Only

Employee + Spouse


Employee + Family

MEC Enhanced

Employee Only

Employee + Spouse


Employee + Family

Limited Day MedicalHEALTH INSURANCE OPTIONS

$106$161$172$249

MonthlyPremium

$184$376$387$523

MonthlyPremium

$298$656$537$895

PLAN FEATURES

CoveredServices MECPlus MECEnhanced LimitedDayMedical

ACAMandatedPreventiveandWellness

Coveredat100% Coveredat100% Coveredat100%

AnnualDeductible None None None

AnnualCo-pay/Co-insuranceandOutofPocketMaximums

Individual:$4,000Family:$7,500



OfficeVisitsandUrgentCare

OfficeVisits-PrimaryCare $20Co-Pay,Limitedto3VisitsAnnually

$20Co-Pay,NoLimit $15Co-Pay,Limitedto10VisitsAnnually

OfficeVisits-Specialist(ExamorConsultation)

ValuePointNetworkDiscount

$40Co-Pay,NoLimit $25Co-pay,Limitedto10VisitsAnnually

UrgentCare $50Co-Pay,Limitedto1VisitAnnually

$50Co-Pay,NoLimit $35Co-payLimitedto3VisitsAnnually

DiagnosticServices

DiagnosticServicesBasic-Labsandx-rays

ValuePointNetworkDiscount(asrelatedtoPrimaryCareVisit)

$50Co-Pay $50Co-Pay-Limitedto3VisitsAnnually

DiagnosticServicesMajor-MRI,CT,PET

ValuePointNetworkDiscount

$400Co-Pay Seebelowunder"OutpatientServices"

InpatientServices $350Co-PayPerDayPerInpatientStayforallCoveredServices

DailyIn-Hospital NoBenefit NoBenefit SubjecttoCo-Pay-Limitedto6DaysAnnually

InpatientPhysicianVisits NoBenefit NoBenefit SubjecttoCo-Pay-Limitedto6DaysAnnually

InpatientSurgery NoBenefit NoBenefit SubjecttoCo-Pay-Limitedto3DaysAnnually

Anesthesia NoBenefit NoBenefit SubjecttoCo-Pay-Limitedto3DaysAnnually

InpatientDiagnosticTesting-All NoBenefit NoBenefit IncludedasInpatientHospitalStayInpatientMentalHealth/SubstanceAbuse/ChemicalDependency

NoBenefit NoBenefit $100Co-Pay-Limitedto6DaysAnnually

Maternity NoBenefit NoBenefit IncludedasInpatientHospitalStay-Limitedto6daysAnnually

OutpatientServicesOutpatientHospitalServices NoBenefit NoBenefit $350Co-Pay-Limitedto2VisitsAnnuallyOutpatientSurgery NoBenefit NoBenefit $350Co-Pay-Limitedto2VisitsAnnuallyOutpatientAnesthesia NoBenefit NoBenefit $350Co-Pay-Limitedto2VisitsAnnuallyOutpatientDiagnosticServicesMajor-MRI,CT,PET

NoBenefit Seeaboveunder"DiagnosticServices"

$350Co-Pay-Limitedto2VisitsAnnually

OutpatientMentalHealth/SubstanceAbuse/ChemicalDependency

NoBenefit NoBenefit $25Co-pay-Limitedto10VisitsAnnually

EmergencyRoom/Services

EmergencyRoomValuePointNetworkDiscount

$400Co-Pay,Limitedto2VisitsAnnually.Maximum$1,000AnnualBenefit

$350Co-Pay,Limitedto1VisitAnnually

OtherServices

AllergyServices NoBenefit NoBenefit$25Co-Pay,IncludedinSpecialistOfficeVisit

HomeHealthCare NoBenefit NoBenefit $25Co-Pay,Limitedto30VisitsAnnuallyTelemedicine(www.Sherpaa.com) PlanPays100% PlanPays100% PlanPays100%

**Thisgridisdesignedtogiveyouahighlevelsidebysidecomparisonofyour3corehealthplans.ALLSERVICESBELOWARESHOWNASIN-NETWORKBENEFITS.ForadetailedlistingofeachplanpleaserefertoTheScheduleofBenefitsinthisenrollmentguide.TheLimitedDayBenefitPlanPaysat150%ofMedicare.

Group ID:FHINS

P.O. Box 1807Draper, Utah 84020Emdeon Payor ID: 88067Customer Service: 877-453-4201

Lifetime Max: None Network Providers Non-Network Providers Benefit Limits Per Calendar Year

Annual Deductibles

Does not include Co-pays.

In-network and Out-of-network are separate

accumulations and do not cross apply

Individual: NoneFamily: None

Individual: NoneFamily: None

Annual Co-pay and Co-Insurance

Out of Pocket Maximums

(Medical and Rx Co-pays apply to the annual out

of pocket maximums)

Individual $4,000Family $7,500

Individual: UnlimitedFamily: Unlimited

Office Visits - Primary Care(exam or consultation) $20 Co-pay, Plan pays 100% No Benefit Limited to 3 visits annually.

Office Visits - Specialist(exam or consultation) Network Discount Card applies No Benefit

Diagnostic Services - Basic labs/x-rays(related to office visit, LabCorp, etc.) Network Discount Card applies No Benefit Included on 3 visits annually.

Diagnostic Services - Major (Facility Charges)(MRI, CT, PET, Nuclear Medicine,etc.) Network Discount Card applies No Benefit

Diagnostic Services - Major (Physician Charges)(MRI, CT, PET, Nuclear Medicine,etc.) Network Discount Card applies No Benefit

Diagnostic Services - Minor(ultrasounds, bone density, ecography,etc) Network Discount Card applies No Benefit

Emergency Room Facilities Network Discount Card applies No Benefit

Emergency Room - All covered services other thanfacility charges Network Discount Card applies No Benefit

Urgent Care Center & 24 Hour Clinic $50 Co-pay, Plan pays 100% No Benefit Limited to 1 visit annually.

Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits

Office Visit Exam & Includes Services For: Plan pays 100% No Benefit Limited to preventive diagnosis only.

Abdominal Aortic Aneurysm Plan pays 100% No Benefit One time screening for males of ages65 to 75 who have ever smoked

Alcohol Misuse Screening and Counseling Plan pays 100% No Benefit

Aspirin use for Men and Women Plan pays 100% No BenefitA low-dose aspirin for prevention of cardiovascular

disease and colorectal cancer in adults aged 50-59 years(see plan document for further criteria)

Blood Pressure Screening Plan pays 100% No BenefitOne screening every two years for ages 18 to 39

One Screening per calendar year for ages 40 and over

Cholesterol Screening Plan pays 100% No Benefit

One screening per calendar year for men 35 and older.Men under 35 who have heart disease or risk factors

for heart disease or women who have heart disease orrisk factors for heart disease

Colorectal Cancer Screening Plan pays 100% No Benefit Screening for adults over age 50

Schedule of Medical Benefits

PHCS Specific Services Network

Insurance Staffers

Enhanced Minimum Essential Coverage (MEC Plus) Plan

PPO Provider Network:

Minimum weekly hours for full time: 30 hours/130 per month

Covered Preventive Services for Adults as defined by CMS Preventive Services

Option ID: INS9I

Limits are per person per calendar year

Beginning on January 1 and ending on December 31

This Plan provides Minimal Essential Coverage for Medical Care.

If the service is not listed on this Schedule of Benefits it is not covered. Claims Address

Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination.

Depression Screening Plan pays 100% No Benefit Screening for depression in the general adult population,including pregnant and postpartum women.

Type 2 Diabetes Screening Plan pays 100% No Benefit Screening for adults with high blood pressure only

Diet Counseling Plan pays 100% No Benefit Screening for adults at higher risk of chronic disease

Hepatitis B Screening Plan pays 100% No Benefit

For members at high risk, including members in countries with 2% or more Hepatitis B prevalence, andU.S. Born people not vaccinated as infants and with at

least on parent born in a region with 8% or moreHepatitis B prevalence

Hepatitis C Screening Plan pays 100% No Benefit For adults at increased risk, and one time for everyoneborn between 1945 - 1965

HIV Screening Plan pays 100% No Benefit Screening for adults at higher risk

Immunizations* Hepatitis A* Hepatitis B* Herpes Zoster* Human Papillomavirus* Influenza (Flu Shot)* Measles, Mumps, Rubella* Meningococcal* Pneumococcal* Tetanus, Diphtheria, Pertussis* Varicella

Plan pays 100% No BenefitListed immunizations are once per calendar year.

Human Papillomavirus shots up to age 26.Pneumococcal shots for adults 65 and older

Latent Tuberculosis Infection Plan pays 100% No Benefit Screening for latent tuberculosis infection (LTBI) inpopulations at increased risk

Lung Cancer Screening Plan pays 100% No Benefit For adults 55 - 80 at high risk for lung cancer becausethey're heavy smokers or have quit in the past 15 years

Obesity Screening and Counseling Plan pays 100% No Benefit

Sexually Transmitted Infection (STI)Screening and Counseling Plan pays 100% No Benefit Prevention counseling for adults at higher risk

Statin Plan pays 100% No Benefit

Adults aged 40-75 years with no history ofcardiovascular disease (CVD) use a low-to moderate-

dose statin for the prevention of CVD events andmortality when they have one or more cardiovascular

disease risk factors, and a calculated 10-year CVD eventrisk of 10% or greater; screening for cardiac risk may

include assessment of blood pressure smoking status,screening for lipid disorders and use of ACC/AHA CVD

to estimate 10-year risk

Syphilis Screening Plan pays 100% No Benefit For all adults at higher risk

Tobacco Use Screening Plan pays 100% No Benefit Screenings for adults and cessationinterventions for tobacco users


Well-Women Visits Plan pays 100% No Benefit

Anemia Screening Plan pays 100% No Benefit For pregnant women

BRCA Counseling Plan pays 100% No Benefit Includes genetic test for women at high risk

Breast Cancer Mammography Screening Plan pays 100% No BenefitScreenings every 1 to 2 years for

women over 40 through age 74. (see plan document forfurther criteria)

Breast Cancer Chemoprevention Counseling Plan pays 100% No Benefit Counseling for women at high risk

Breastfeeding Consultations Plan pays 100% No Benefit

Providing interventions during pregnancy and after birthto support breastfeeding. Comprehensive support andcounseling from trained providers, as well as access to

breastfeeding supplies, for pregnant and nursing women.

Covered Preventive Services for Women - Including Pregnant Women

Cervical Cancer Screening Plan pays 100% No Benefit

For ages 21-29, PAP smear every 3 years

For ages 30-65, with cytology and human papillomavirustesting (HPV) with Pap smear every 5 years or a regular

cytology alone (without HPV testing) every 3 years

Women with an average risk shouldn’t be screened more than once every 3 years

Chlamydia Infection Screening Plan pays 100% No Benefit For younger women and women at high risk

Contraception Plan pays 100% No Benefit

Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education

and counseling, not including abortifacient drugs.Counseling and follow-up care are included with this

benefit. Birth control pills will be covered under your Rxbenefits.

Depression Screening Plan pays 100% No Benefit Screening for depression in the general adult population,including pregnant and postpartum women

Domestic and Interpersonal Violence Screening Plan pays 100% No Benefit

Annual screening for women to obtain a referral to initial intervention services, which include counseling,

education, harm reduction strategies and referral toappropriate support services.

Folic Acid Supplements Plan pays 100% No Benefit All women who are planning or capable of pregnancytake a daily supplement containing 0.4-0.8mg

Gestational Diabetes Screening Plan pays 100% No BenefitFor women 24 to 28 weeks pregnant and / or at

high risk of developing gestational diabetes should bescreened prior to 24 weeks of gestation

Gonorrhea Screening Plan pays 100% No Benefit For all women at higher risk

Hepatitis B Screening Plan pays 100% No Benefit For pregnant women at their first prenatal visit

Human Immunodeficiency Virus (HIV)Screening and counseling Plan pays 100% No Benefit For women sexually active

Human Paillomavirus (HPV) DNA Test Plan pays 100% No Benefit One test every 3 years for woment withnormal cytology results who are 30 or older

Osteoporosis Screening Plan pays 100% No Benefit For women over age 60 or at high risk

Preeclampsia Plan pays 100% No Benefit Screening for preeclampsia in pregnant women withblood pressure measurements throughout pregnancy

Rh Incompatibility Screening Plan pays 100% No Benefit For pregnant women and follow-up testingfor women at higher risk

Tobacco Use Screening and interventions Plan pays 100% No Benefit

Syphilis Screening Plan pays 100% No Benefit For all pregant woment or other women at increase risk

Sexually Transmitted Infection (STI) and Sexually transmitted Diseases (STD) Screening andcounseling, includes Gonorrhea & Syphilis Screening

Plan pays 100% No Benefit For sexually active women

Urinary Tract or Other Infection Screening forPregnant Women Plan pays 100% No Benefit


Alcohol and Drug Use Assessments Plan pays 100% No Benefit

Autism Screening Plan pays 100% No Benefit For children at 18 months to 24 months

Behavioral Assessments Plan pays 100% No Benefit For children to age 18

Blood Pressure Screening Plan pays 100% No Benefit For children to age 18

Cervical Dysplasia Screening Plan pays 100% No Benefit For sexually active females

Congenital Hypothyroidism Screening Plan pays 100% No Benefit For newborns

Contraception Plan pays 100% No Benefit

Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education

and counseling, not including abortifacient drugs.Counseling and follow-up care are included with this

benefit. Birth control pills will be covered under your Rxbenefits.

Covered Preventive Services for Children

Depression Screening Plan pays 100% No Benefit Screening for major depressive disorder (MDD) inadolescents aged 12 to 18 years

Developmental Screening Plan pays 100% No Benefit For children under age 3 andsurveillance throughout childhood

Dyslipidemia Screening Plan pays 100% No Benefit For children at high risk of lipid disorders

Fluoride Chemoprevention Supplements Plan pays 100% No Benefit For children without fluoride in their water sources

Gonorrhea Preventive Medicaiton for the Eyes of AllNewborns Plan pays 100% No Benefit

Hearing Screenings Plan pays 100% No Benefit For all newborns

Height, Weight and Body Mass Index Measurements Plan pays 100% No Benefit For children to age 18

Hematocrit or Hemoglobin Screening Plan pays 100% No Benefit For children to age 18

Hemoglobinopathies of Sickle Cell Screening Plan pays 100% No Benefit For all newborns

HIV Screening Plan pays 100% No Benefit For sexually active children

Hypothyroidism Screening for Newborns Plan pays 100% No Benefit

Immunizations:* Acellular Pertussis* Diphtheria, Tetanus, Pertussis* Haemophilus influenza type B* Hemophilia* Hepatitis A* Hepatitis B* Human Papillomavirus* Inactivated Poliovirus* Influenza (Flu Shot)* Measles, Mumps, Rubella* Meningococcal* Meningococcal B Vaccine* Pneumococcal* Rotavirus* Varicella

Plan pays 100% No Benefit For children to age 18

Interpersonal and Domestic Violence Screening Plan pays 100% No Benefit

Annual screening for women to obtain a referral to initial intervention services, which include counseling,

education, harm reduction strategies and referral toappropriate supportive services.

Iron Supplements Plan pays 100% No Benefit For children ages 6 to 12 months at risk of anemia

Lead Screening Plan pays 100% No Benefit For children at risk of exposure

Medical History Plan pays 100% No Benefit For all children throughout development

Obesity Plan pays 100% No Benefit

Screening for obesity in children and adolescents sixyears and older and offer to refer them to

comprehensive, intensive behavioral interventions topromote improvements in weight status

Oral Health Plan pays 100% No Benefit At risk assessment for your childrenages newborn to age 10

Phenylketonuria (PKU) Screening Plan pays 100% No Benefit For genetic disorders in newborns

Sexually Transmitted Infection (STI) and Sexually Transmitted Diseases (STD)Screening and Counseling

Plan pays 100% No Benefit For children at higher risk, includes gonorrhea preventivemedication for newborn eyes

Syphilis Screening Plan pays 100% No Benefit For all adolescents at higher risk

Tuberculin Testing Plan pays 100% No Benefit For children at higher risk of tuberculosis to age 18

Vision Screening Plan pays 100% No Benefit screening at least once in all children ages three to fiveyears to detect amblyopia or its risk factors

Prescription Benefits

Covered Prescription Drugs - OptumRx

Customer Service: 1-844-265-1719

Pre-Auth Line: 1-844-265-1719

Rx Bin:610011

Rx PCN: IRX

Rx GROUP: FH2FHTT

Generic Prescriptions <$9.99 = 100% coinsurance

Generic Prescriptions >$10 = 45% coinsurance

Brand Name Prescriptions = No Benefit

No Benefit

Specialty Medications: No Benefit

All prescriptions are limited to 31 day supply

Insulin and Rescue inhalers are covered.

$600 benefit maximum per family per year.

Telemedicine

Sherpaa Go to www.sherpaa.com for more information.

Effective: 1/1/2019

No Pre-existing for employees or dependents.

Dependents are covered to age 26 regardless of student or marital status.Timely Filing: Claims must be filed within 6 months from the date the service incurred. Life Threatening services incurred at an out of network provider will be paid in network. Pre-existing is not applicable for any member of the Plan.Coordination of benefits - Non duplicating meaning this Plan will not pay in excess of the normal plan benefit in absence of other insurance.

We believe this coverage is a non grandfathered health plan under the Patient Protection and Affordable Care Act. (PPACA)

Visit www.talltreehealth.com to view the Plan Document, Schedule of Benefits, enrollment information, your claims history, link to the PPO network and more.All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a guarantee of payment.

Rural Area is defined as 30 miles. If preventive services are not available within 30 miles of your residence the provider will be paid in network.

Note: Any non-allowed or not covered amounts or services are the responsibility of the patient and are not included in the Out-of-Pocket Maximum.

Plan pays 100%

Out of Country services will be paid as a in-network for covered medical emergencies only, to a maximum of $15,000 of billed charges.









Group ID: FHINS

Claims Address

P.O. Box 1807 PPO Provider Network:Draper, Utah 84020 PHCS Specific Services NetworkEmdeon Payor ID: 88067Customer Service: 877-453-4201

Lifetime Max: None Network Providers Benefit Limits Per Calendar Year

Annual Deductibles


In-network and Out-of-network are separate accumulations

and do not cross apply

Individual: None Family: None

Annual Co-pay and Co-Insurance Out of Pocket Maximums

(Medical and Rx Co-pays apply to the annual out of pocket

maximums)Individual $7,150 Family $14,300

Office Visits - Primary Care (exam or consultation)$20 Co-pay, Plan pays 100%

Office Visits - Specialist (exam or consultation)$40 Co-pay, Plan pays 100%

Diagnostic Services - Basic labs/x-rays (related to office visit, LabCorp, etc.) $50 Co-pay, Plan pays 100%

Diagnostic Services - Major (Facility Charges) (MRI, CT, PET, Nuclear Medicine,etc.)

$400 Co-pay, Plan pays 100% of allowed amount

Diagnostic Services - Major (Physician Charges) (MRI, CT, PET, Nuclear Medicine,etc.) Plan pays 100% of allowed amount

Diagnostic Services - Minor(ultrasounds, bone density, ecography,etc) $50 Co-pay, Plan pays 100%

Emergency Room Facilities$400 Co-pay, Plan pays 100%

Emergency Room - All covered services other than facility charges $400 Co-pay, Plan pays 100%

Urgent Care Center & 24 Hour Clinic$50 Co-pay, Plan pays 100%

Wellness Office Visits and Lab Services Network Providers Benefit Limits

Office Visit Exam & Includes Services For:Plan pays 100% Limited to preventive diagnosis only.

Abdominal Aortic AneurysmPlan pays 100% One time screening for males of ages 65 to 75 who have ever

smoked

Alcohol Misuse Screening and CounselingPlan pays 100%

Aspirin use for Men and WomenPlan pays 100%

A low-dose aspirin for prevention of cardiovascular disease and colorectal cancer in adults aged 50-59 years (see plan document for

further criteria)Blood Pressure Screening

Plan pays 100% One screening every two years for ages 18 to 39One Screening per calendar year for ages 40 and over

Cholesterol Screening Plan pays 100%One screening per calendar year for men 35 and older. Men under 35

who have heart disease or risk factors for heart disease or women who have heart disease or risk factors for heart disease

Colorectal Cancer ScreeningPlan pays 100% Screening for adults over age 50

Depression ScreeningPlan pays 100% Screening for depression in the general adult population, including

pregnant and postpartum women.

Type 2 Diabetes ScreeningPlan pays 100% Screening for adults with high blood pressure only

This Plan provides Minimal Essential Coverage for Medical Care.

If the service is not listed on this Schedule of Benefits it is not covered.

Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination.Minimum weekly hours for full time: 30 hours/130 per month

Non-Network Providers

Individual $500Family $1,000

All benefits and accumulations are on a Calendar Year.

Individual: Unlimited Family: Unlimited

Deductible, Plan pays 60% of allowed amount



$400 Co-pay, Plan pays 60% of allowed amount



$400 Co-pay, Plan pays 100% of allowed amount Limited to 2 visits per year.

Maximum: $1,000No Benefit


Covered Preventive Services for Adults as defined by CMS Preventive ServicesNon-Network Providers










Insurance Staffers

Minimum Essential Coverage (Enhanced MEC) PlanSchedule of Medical Benefits

Option ID: INS9C

Diet CounselingPlan pays 100% Screening for adults at higher risk of chronic disease

Hepatitis B Screening

Plan pays 100%

For members at high risk, including members in countries with 2% or more Hepatitis B prevalence, and

U.S. Born people not vaccinated as infants and with at least on parent born in a region with 8% or more

Hepatitis B prevalence

Hepatitis C ScreeningPlan pays 100% For adults at increased risk, and one time for everyone born between

1945 - 1965

HIV ScreeningPlan pays 100% Screening for adults at higher risk

Immunizations* Hepatitis A* Hepatitis B* Herpes Zoster* Human Papillomavirus* Influenza (Flu Shot)* Measles, Mumps, Rubella* Meningococcal* Pneumococcal* Tetanus, Diphtheria, Pertussis* Varicella

Plan pays 100% Listed immunizations are once per plan year. Human Papillomavirus shots up to age 26. Pneumococcal shots for adults 65 and older

Latent Tuberculosis Infection Plan pays 100% Screening for latent tuberculosis infection (LTBI) in populations at increased risk

Lung Cancer ScreeningPlan pays 100% For adults 55 - 80 at high risk for lung cancer because they're heavy

smokers or have quit in the past 15 years

Obesity Screening and CounselingPlan pays 100%

Sexually Transmitted Infection (STI) Screening and CounselingPlan pays 100% Prevention counseling for adults at higher risk

Statin Plan pays 100%

Adults aged 40-75 years with no history of cardiovascular disease (CVD) use a low-to moderate-dose statin for the prevention of CVD events and mortality when they have one or more cardiovascular

disease risk factors, and a calculated 10-year CVD event risk of 10% or greater; screening for cardiac risk may include assessment of

blood pressure smoking status, screening for lipid disorders and use of ACC/AHA CVD to estimate 10-year risk

Syphilis Screening Plan pays 100% For all adults at higher risk

Tobacco Use Screening Plan pays 100% Screenings for adults and cessation interventions for tobacco users

Wellness Office Visits and Lab Services Network Providers Benefit Limits

Well-Women Visits Plan pays 100%

Anemia Screening Plan pays 100% For pregnant women

BRCA Counseling Plan pays 100% Includes genetic test for women at high risk

Breast Cancer Mammography Screening Plan pays 100%Screenings every 1 to 2 years for

women over 40 through age 74. (see plan document for further criteria)

Breast Cancer Chemoprevention Counseling Plan pays 100% Counseling for women at high risk

Breast Pumps Plan pays 100% One per delivery. Purchase Breast Pump at a local retail store and submit the receipt for reimbursement

Breastfeeding Consultations Plan pays 100%

Providing interventions during pregnancy and after birth to support breastfeeding. Comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant

and nursing women.

Cervical Cancer Screening Plan pays 100%

For ages 21-29, PAP smear every 3 years

For ages 30-65, with cytology and human papillomavirus testing (HPV) with Pap smear every 5 years or a regular cytology alone

(without HPV testing) every 3 years

Women with an average risk shouldn’t be screened more than once every 3 years

Chlamydia Infection Screening Plan pays 100% For younger women and women at high risk

Contraception Plan pays 100%

Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs. Counseling and follow-up care are included with this benefit. Birth control pills will be covered under

your Rx benefits.

Depression Screening Plan pays 100% Screening for depression in the general adult population, including pregnant and postpartum women











Covered Preventive Services for Women - Including Pregnant WomenNon-Network Providers














Domestic and Interpersonal Violence Screening Plan pays 100%Annual screening for women to obtain a referral to initial intervention

services, which include counseling, education, harm reduction strategies and referral to appropriate support services.

Folic Acid Supplements Plan pays 100% All women who are planning or capable of pregnancy take a daily supplement containing 0.4-0.8mg

Gestational Diabetes Screening Plan pays 100%For women 24 to 28 weeks pregnant and / or at

high risk of developing gestational diabetes should be screened prior to 24 weeks of gestation

Gonorrhea Screening Plan pays 100% For all women at higher risk

Hepatitis B Screening Plan pays 100% For pregnant women at their first prenatal visit

Human Immunodeficiency Virus (HIV) Screening and counseling Plan pays 100% For women sexually active

Human Paillomavirus (HPV) DNA Test Plan pays 100% One test every 3 years for woment with normal cytology results who are 30 or older

Osteoporosis Screening Plan pays 100% For women over age 60 or at high risk

Preeclampsia Plan pays 100% Screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy

Rh Incompatibility Screening Plan pays 100% For pregnant women and follow-up testing for women at higher risk

Tobacco Use Screening and interventions Plan pays 100%

Syphilis Screening Plan pays 100% For all pregant woment or other women at increase risk

Sexually Transmitted Infection (STI) and Sexually transmitted Diseases (STD) Screening and counseling, includes Gonorrhea & Syphilis Screening

Plan pays 100% For sexually active women

Urinary Tract or Other Infection Screening for Pregnant Women Plan pays 100%

Wellness Office Visits and Lab Services Network Providers Benefit LimitsAlcohol and Drug Use Assessments

Plan pays 100%

Autism ScreeningPlan pays 100%

For children at 18 months to 24 months

Behavioral AssessmentsPlan pays 100%

For children to age 18

Blood Pressure ScreeningPlan pays 100%

For children to age 18

Cervical Dysplasia ScreeningPlan pays 100%

For sexually active females

Congenital Hypothyroidism ScreeningPlan pays 100%

For newborns

Contraception Plan pays 100%

Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs. Counseling and follow-up care are included with this benefit. Birth control pills will be covered under

your Rx benefits.

Depression Screening Plan pays 100% Screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years

Developmental Screening Plan pays 100% For children under age 3 and surveillance throughout childhood

Dyslipidemia Screening Plan pays 100% For children at high risk of lipid disorders

Fluoride Chemoprevention Supplements Plan pays 100% For children without fluoride in their water sources

Gonorrhea Preventive Medicaiton for the Eyes of All Newborns Plan pays 100%

Hearing Screenings Plan pays 100% For all newborns

Height, Weight and Body Mass Index Measurements Plan pays 100% For children to age 18

Hematocrit or Hemoglobin Screening Plan pays 100% For children to age 18

Hemoglobinopathies of Sickle Cell Screening Plan pays 100% For all newborns

HIV Screening Plan pays 100% For sexually active children

Hypothyroidism Screening for Newborns Plan pays 100%























Covered Preventive Services for ChildrenNon-Network Providers











Immunizations: * Acellular Pertussis * Diphtheria, Tetanus, Pertussis * Haemophilus influenza type B * Hemophilia * Hepatitis A * Hepatitis B * Human Papillomavirus * Inactivated Poliovirus * Influenza (Flu Shot) * Measles, Mumps, Rubella * Meningococcal * Meningococcal B Vaccine * Pneumococcal * Rotavirus * Varicella

Plan pays 100% For children to age 18

Interpersonal and Domestic Violence Screening Plan pays 100%Annual screening for women to obtain a referral to initial intervention

services, which include counseling, education, harm reduction strategies and referral to appropriate supportive services.

Iron Supplements Plan pays 100% For children ages 6 to 12 months at risk of anemia

Lead Screening Plan pays 100% For children at risk of exposure

Medical History Plan pays 100% For all children throughout development

Obesity Plan pays 100%Screening for obesity in children and adolescents six years and older

and offer to refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status

Oral Health Plan pays 100% At risk assessment for your children ages newborn to age 10

Phenylketonuria (PKU) Screening Plan pays 100% For genetic disorders in newborns

Sexually Transmitted Infection (STI) Screening and Counseling Plan pays 100% For children at higher risk, includes gonorrhea preventive medication for newborn eyes

Syphilis Screening Plan pays 100% For all adolescents at higher risk

Tuberculin Testing Plan pays 100% For children at higher risk of tuberculosis to age 18

Vision Screening Plan pays 100% screening at least once in all children ages three to five years to detect amblyopia or its risk factors



Pre-Auth Line: 1-844-265-1719

Rx Bin: 610011

Rx PCN: IRX

Rx GROUP: FH2FHTT






Insulin and Rescue inhalers are covered.

$600 benefit maximum per family per year.

Sherpaa Go to www.sherpaa.com for more information.

Effective: 01/01/2019











Plan pays 100%


No Benefit

Telemedicine



All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a

guarantee of payment.

Claims are determined upon receipt of the claim and any additional information required to make a benefit determination.

Note: Any non-allowed or not covered amounts or services are the responsibility of the patient and are not included in the Out-of-PocketMaximum.Dependents are covered to age 26 regardless of student or marital status.

Timely Filing: Claims must be filed within 6 months from the date the service incurred. Life Threatening services incurred at an out ofnetwork provider will be paid in network. Pre-existing is not applicable for any member of the Plan.

Coordination of benefits - Non duplicating meaning this Plan will not pay in excess of the normal plan benefit in absence of other insurance. Rural Area is defined as 30 miles. If preventive services are not available within 30 miles of your residence the provider will be paid in network.No Pre-existing for employees or dependents. Out of Country services will be paid as a in-network for covered medical emergencies only, to a maximum of $15,000 of billed charges.We believe this coverage is a non grandfathered health plan under the Patient Protection and Affordable Care Act. (PPACA)

Visit www.talltreehealth.com to view the Plan Document, Schedule of Benefits, enrollment information, your claims history, link to the PPO network and more.

http://www.sherpaa.com/









Group ID: FHINS

* Pre-Certification: Arizona Foundation - FoundationUM (AZF) 833-291-2519

Claims Address:P.O. Box 1807 PPO Provider Network:Draper, Utah 84020 Physicians: PHCS- Specific Services NetworkEmdeon Payor ID: 88067 Facilities: 150% of MedicareCustomer Service: 877-453-4201

Minimum hours for full time: 130 per month/30 per weekLifetime Max: None Network Providers Non-Network Providers Benefit Limits Per Calendar Year

Annual Deductibles




Individual: NoneFamily: None No Benefit

Annual Co-pay and Co-Insurance

Out of Pocket Maximums

(Medical and Rx co-pays apply to the annual out

of pocket maximums)

Individual: $5,000Family: $10,000 No Benefit

Office Visits - Primary Care(exam or consultation) $15 Co-pay, Plan pays 100% No Benefit Limited to 10 visits per calendar year

Office Visits - Specialist(exam or consultation) $25 Co-pay, Plan pays 100% No Benefit Limited to 10 visits per calendar year

Office Services - basic services with exam(does not include pain management, chemo, surgical services)

Plan pays 100% No Benefit

Telemedicine through Sherpaa Go to www.sherpaa.com for more information.

Wellness Care - Adult Plan pays 100% No Benefit

Wellness Care - Children Plan pays 100% No Benefit

Allergy Services Covered 100% after Specialist Office Visit Co-pay No Benefit

Ambulance(Ground Services Only) $250 copay, Plan pays 100% No Benefit Limited to 1 visit per calendar year

Birth Control / IUD No Benefit No Benefit

Breast Pumps One per delivery. Purchase Breast Pump at a local retail store and submit the receipt for reimbursement

Chemical Dependency - Inpatient

Limited to 6 days per calendar year

** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment

Chemical Dependency - Outpatient $25 copay, Plan pays 100% No Benefit Limited to 6 visits per calendar year

Chemotherapy / Radiation Therapy No Benefit No Benefit

Chiropractic Services No Benefit No Benefit

Colonoscopy (For Medical Reasons) No Benefit No Benefit

Diagnostic Services - Basic labs/x-rays(related to office visit, LabCorp, etc.) $50 Co-pay, Plan pays 100% No Benefit Limited to 3 visits per calendar year

Diagnostic Services - Major(MRI, CT, PET, Nuclear Medicine,etc.)

Covered 100% after Outpatient Services Co-pay No Benefit Limited to 2 visits per calendar year

Diagnostic Services - Minor (ultrasounds, bone density, echography, etc) $350 copay, Plan pays 100% No Benefit Limited to 2 visits per calendar year

Diabetic Education No Benefit No Benefit

Dialysis No Benefit No Benefit

Durable Medical Equipment(includes orthotics & prosthetics) No Benefit No Benefit

Emergency Room Facilities

Limited to 1 visit per calendar year


Emergency Room - All covered services other than facility charges

Plan pays 100% after $350 Co-pay No Benefit Limited to 1 visit per calendar year

Gastric Bypass Surgery / Lap Banding No Benefit No Benefit

Home Health Care $25 copay, Plan pays 100% No Benefit Limited to 30 visits per calendar year

Hospice Care No Benefit No Benefit

Insurance Staffers

Plan pays 100%

$350 copay, Plan pays 100% (Plan payment based on 150% of Medicare Allowable Payment)

Limited Day Medical Plan 7 Schedule of Medical Benefits

Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination.

Plan pays 100%

$100 copay, Plan pays 100%, (Plan payment based on 150% of Medicare Allowable Payment)

This Plan provides Minimal Value Coverage for Medical Care.


Limits are per person per calendar year.

Beginning January 1 and ending December 31.

Wellness Care includes, but not limited to: pap smear, mammogram, prostate screening, gynecological exam, routine physical exam, routine vision exam for children, routine hearing exam for children, immunizations and related laboratory blood tests, colonoscopies. Other preventive services as identified by the Patient Protection and Affordable Care Act (PPACA) will be covered.

AZF * Hospital Facility - Inpatient Services


* Pre Certification Required. Failure to obtain Pre Certification may result in a reduction of $250 or denial of benefits.


Hospital - Inpatient Surgery Covered 100% after Inpatient Services Co-pay No Benefit


* Pre Certification Required for inpatient services Attending Physician and Surgeon charges during an inpatient hospital confinement

Covered 100% after Inpatient Services Co-pay No Benefit Limited to 6 days per calendar year

Anesthesiologist charges during an inpatient hospital confinement

Covered 100% after Inpatient Services Co-pay No Benefit Limited to 3 days per calendar year

Hospital - Outpatient Services(any charge billed from a hospital)

Limited to 2 visits per calendar year


Hospital - Outpatient Surgery Covered 100% after Outpatient Services Co-pay No Benefit Limited to 3 days per calendar year

Attending Physician, Surgeon and Anesthesiologist charges during an outpatient hospital confinement

Covered 100% after Outpatient Services Co-pay No Benefit Limited to 3 days per calendar year

Infertility Services No Benefit No Benefit

Maternity - Prenatal Office Visits Only (billed separately from total delivery) Plan pays 100% No Benefit

Maternity - (Labs, x-rays, ultrasounds and related covered services) No Benefit No Benefit

* Maternity - Facility Covered 100% after Inpatient Services Co-pay No Benefit

Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement

Covered 100% after Inpatient Services Co-pay No Benefit

Medical Supplies (Including but not limited to: Insulin, Diabetic test strips, Insulin pumps, etc.) These supplies may also be covered under Prescription Benefit.

No Benefit No Benefit

AZF * Mental Health - Inpatient



Mental Health - Outpatient $25 copay, Plan pays 100% No Benefit Limited to 6 visits per calendar year

Outpatient TherapyPhysical, Speech and Occupational No Benefit No Benefit

Outpatient Surgery performed in an office or urgent care facility No Benefit No Benefit

Skilled Nursing No Benefit No Benefit

Sleep Studies No Benefit No Benefit

Sterilization for Women Plan pays 100% No Benefit

Sterilization for Men No Benefit No Benefit

TMJ and Orthognathic No Benefit No Benefit

Transplant Facility No Benefit No Benefit

Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement No Benefit No Benefit

Urgent Care Center & 24 Hours $35 Co-pay, Plan pays 100% No Benefit Limited to 3 visits per calendar year



Pre-Auth Line: 1-844-265-1719

Rx Bin: 610011

Rx PCN: IRX

Rx GROUP: FH2FHTT

Generic Prescriptions: 20% Coinsurance per drug

Brand Prescriptions: No Benefit

No Benefit



Plan maximum is $100 per drug and covers retail only

Effective: 1/1/2019

** Payment will be capped at 150% of the Medicare Allowable Payment. If provider does not accept the Medicare Allowable Amount, patient may be

balance billed.

$350 Co-pay, Plan pays 100% (Plan payment based on 150% of Medicare Allowable Payment)

$350 copay, Plan pays 100% (Plan payment based on 150% of Medicare Allowable Payment)

Coordination of benefits - Non duplicating meaning this Plan will not pay in excess of the normal plan benefit in absence of other insurance.

$100 copay, Plan pays 100%, (Plan payment based on 150% of Medicare Allowable Payment)

No Pre-existing for employees or dependents.

Note: Any non-allowed or not covered amounts or services are the responsibility of the patient and are not included in the Out-of-Pocket Maximum.

Timely Filing - Claims must be filed within 12 months from the date of service.


Out of Country services will be paid as a in-network for covered medical emergencies only, to a maximum of $15,000 of billed charges.

Rural Area is defined as 30 miles. If covered services are not available in the network within 30 miles the provider will be paid in network.

Dependents are covered to age 26 regardless of student or marital status.


All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a guarantee of payment.



We believe this coverage is a non grandfathered health plan under the Patient Protection and Affordable Care Act. (PPACA)









ABOUT MY BENEFITS

Q1. What does the “Network Discount Card Applies” mean in the MEC Plus?

The MEC Plus does not cover services that state “Network Discount Card Applies". The Value Point program allows you to access the Multiplan Network (same network in your MEC Plus) for the “discounted provider” rate. You get to pay the discounted provider rate – i.e. the contractual rate your provider (Doctor) has with the network (Multiplan) - https://www.multiplan.com/providers/valuepoint_faq.cfmKeep in mind; You will receive a separate Value Point Card.

Q2. What is Minimum Essential Coverage and why are there 2 options?

Minimum Essential Coverage is a required mandatory offering under the Affordable Care Act’s Employer Mandate provision. We offer a MEC Plus and MEC Enhanced in order to increase the level of benefits and give you more options.

Q3. How does my prescription drug coverage work?

All health plans use Optum RX as the prescription vendor or PBM (Pharmacy Benefit Manager). Each plan has different levels of restrictions based on the plan’s premium. Please refer to the RX documents in this enrollment guide for more information.

Q4. What is the Limited Day Medical Benefit (LDM)?

The LDM is designed to give you the best possible benefit for the lowest premium. Along with the lowest premium come certain benefits and certain limitations. The LDM offers “first dollar coverage” – meaning you don’t have to meet a deductible for you to receive benefits under the plan. The plancovers hospital inpatient, outpatient, surgery, maternity benefits and more. However, the plan limitsthe days and/or visits for each benefit. Please refer to the schedule of benefits to understand thelimits.

AMERICAN MEDICAL PLAN

PROVIDER NETWORKS &CONTACT INFORMATION

Understanding Your Provider Networks and Who to Contact

Medical Network - https://www.multiplan.com/webcenter/portal/ProviderSearchAll our medical plans use the PHCS Network through Multiplan. This is considered your in-network benefit for physician and facility (I.E. Doctors and Hospitals). The link below will help you find an in-network provider.

Pharmacy – RX Coverage - www.OptumRx.comOptum RX manages the Pharmacy Benefit Management (PBM) component of your health plan. Please refer to the Optum handouts in this guide to better manage your

Telemedicine - https://www.sherpaa.comAll medical plans come with a telemedicine service that allows you to communicate with a Doctor.

Talltree Administrators - http://www.talltreehealth.comTalltree provides the function of day to day support. Talltree can help with missing ID cards, change of address and other customer service functions.877.453.4201


https://www.multiplan.com/webcenter/portal/ProviderSearch

www.OptumRx.com

https://www.sherpaa.com

http://www.talltreehealth.com

More and more employers are adopting consumer-driven healthcare programs to replace or complement their

traditional insurance benefit plans. aluePoint by MultiPlan® is a medical access card program designed to help you reach

this growing population of consumers. Participating providers have specifically agreed to extend their MultiPlan Networ contracted discounts to your eligible members in exchange for payment in full by the member at the point of service.

ValuePoint by MultiPlan

®

Imagine more…

Imagine the best of an insurance-based PPO network tailored for non-insurance programs.

What It Offers Who Should Use It How It Works

• Provider Choice

o 1,300 hospitals

o 60,000 ancillary facilities

o 450,000 practitioner locations

• Savings

o National average savings of 39%for practitioner claims

o National average savings of 28%for ancillary facilities

o National average hospital savingsof 22% for inpatient claims, 21% for outpatient claims

• Programs like shopping clubs thatmay want to partially subsidize fees

• Employers who want a fully orpartially funded alternative totraditional plans

• Employers who want to complementa limited benefit pla

• Employers who want to complementa consumer-directed health plan witha fund or account like an FSA, HRA or HSA

• Member chooses a provider fromonline or telephone directory

• You confirm member eligibility witID card, letter or phone call

• Member presents his/her memberID card featuring the ValuePoint logoat appointment

• If needed, provider calls thenumber on the ID card to obtain thecontractual reimbursement amountfor the service

• The provider collects the discountedamount in full from the member orestablishes payment schedule

Applicable Markets

multiplan.com

MultiPlan, Inc. 115 Fifth Avenue, New York, NY 10003 • multiplan.com

© 2016 MultiPlan, Inc. All rights reserved. MKT5096 10/2016

ValuePoint by MultiPlan® Participating Providers

The table below represents the number of locations by provider type and state as of October 2016. Note that there may be

overlap in the location counts for primary care physicians (PCPs) and specialists.

State Facilities Practitioners

Hospital Ancillary Primary Specialist

Alabama 44 970 2,440 6,620

Alaska 12 163 201 848

Arizona 67 2,287 1,386 4,835

Arkansas 38 576 634 2,719

California 162 5,408 8,115 27,579

Colorado 23 1,195 1,189 5,256

Connecticut 5 694 1,484 5,854

Delaware 2 187 182 864

Dist. of Columbia 2 71 270 693

Florida 34 5,032 7,314 23,203

Georgia 32 2,186 2,298 10,705

Hawaii 4 77 177 1,044

Idaho 14 230 329 1,726

Illinois 24 2,640 1,600 8,172

Indiana 34 1,427 1,458 6,933

Iowa 15 724 618 2,878

Kansas 16 722 869 3,491

Kentucky 9 891 1,255 5,646

Louisiana 46 1,399 1,902 6,684

Maine 10 188 708 1,952

Maryland 18 1,239 2,544 8,002

Massachusetts 8 1,002 1,535 10,603

Michigan 30 1,701 2,182 7,377

Minnesota 27 839 671 2,514

Mississippi 28 617 658 2,444

Missouri 26 1,581 2,138 6,778

StateFacilities Practitioners

Hospital Ancillary Primary Specialist

Montana 3 128 105 488

Nebraska 12 428 251 1,178

Nevada 9 758 1,324 5,183

New Hampshire 8 181 345 1,678

New Jersey 11 1,834 6,610 15,052

New Mexico 15 458 501 2,715

New York 71 3,596 13,884 49,093

North Carolina 15 1,491 1,722 12,097

North Dakota 4 77 112 399

Ohio 39 2,904 2,695 10,371

Oklahoma 31 846 756 3,249

Oregon 17 628 891 6,402

Pennsylvania 46 3,107 5,608 18,285

Rhode Island 7 188 701 1,643

South Carolina 10 870 1,929 6,673

South Dakota 10 109 265 1,183

Tennessee 31 1,827 1,745 8,856

Texas 146 6,106 8,314 29,619

Utah 15 406 2,639 9,663

Vermont 2 62 241 644

Virginia 6 1,206 2,359 6,460

Washington 26 1,048 3,581 16,944

West Virginia 10 359 807 2,406

Wisconsin 34 930 1,576 7,362

Wyoming 3 84 168 370

Unique Totals 1,311 63,677 103,286 383,433

®

optumrx.com is a fast, easy and secure way to get the information you need to make the most of your pharmacy benefit.

Website features and tools

Set up your online account at optumrx.com and:

• Compare medication prices at different pharmacies

• Locate a network pharmacies

• Manage medication for covered dependents and spouses

• View real time benefits and claims history

• You can save time, money and improve your health

• Save time — Skip the pharmacy line. Order medications youtake regularly online and make fewer trips to the pharmacy.

Our digital tools

My medication reminders

Manage text message reminders online.1


optumrx.com

While on the go

Access your pharmacy benefits and manage your prescriptions from your smartphone or tablet with the OptumRx App.

• Find drug prices and lower-cost alternatives

• View your claims history

• Locate a pharmacy

• Access your ID card, if your plan allows

• Manage medication reminders

• Transfer retail prescriptions to home delivery

• Refill or renew home delivery prescriptions

Visit optumrx.com today.

Download the OptumRx App now from the Apple® App Store or Google Play™.

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners.

© 2018 Optum, Inc. All rights reserved. 64538A-042018


MINIMUM VALUE PLAN (MVP)

Understand the Value

The Minimum Value Plan (MVP) is a high deductible plan. The MVP plan does include the required MEC services and does prevent the employee from being taxed the “Individual Mandate” penalty tax by purchasing Minimum Essential Coverage through their employer. Unlike the plans being offered on the Exchange and individual market this MVP does have a list of services that are not covered by the plan. The MVP plan covers the following services after your $7,150 (individual) deductible is met; Emergency Room Services, Inpatient Hospital Services, Primary Care and Specialist visits, Imaging, Laboratory Services, X-rays and Diagnostic Imaging, and certain Generic and Preferred Brand drugs. Please pay close attention to the list of excluded benefit categories

* Please note: If you elect the MVP a Personal Health Questionnaire is required.

Group ID: FHINS

Claims Address:P.O. Box 1807Draper, Utah 84020Emdeon Payor ID: 88067Customer Service: 877-453-4201

Lifetime Max: None Network Providers Non-Network

Annual Deductibles




Deductible applies to Out of Pocket

Individual: $7,150 Family: $14,300

Individual $14,300 Family $28,600

Annual Co-pay and Co-Insurance Out of Pocket

Maximums

(Medical and Rx Co-pays apply to the annual out

of pocket maximums)

Deductible applies to Out of Pocket

Individual: $7,150 Family: $14,300

Individual: Unlimited Family: Unlimited

Office Visits - Primary Care (exam or consultation) $50 Co-pay, Plan pays 60% Deductible, Plan pays 60% of allowed amount

Office Visits - Specialist (exam or consultation) $70 Co-pay, Plan pays 60% Deductible, Plan pays 60% of allowed amount

Office Services - basic services with exam (does not include pain management, chemo, surgical services) Plan pays 60% Deductible, Plan pays 60% of

allowed amount

Wellness Care - Adult Plan pays 100% Deductible, Plan pays 40% of allowed amount

Wellness Care - ChildrenPlan pays 100% Deductible, Plan pays 40% of

allowed amount

Ambulance

Birth Control / IUD Plan pays 100% Deductible, Plan pays 60% of allowed amount

Breast Pumps

* Chemical Dependency - Inpatient

Chemical Dependency Inpatient - All covered services other than facility charges Deductible, Plan pays 100% Deductible, Plan pays 60% of

allowed amount

Chemical Dependency - Outpatient

Chemotherapy / Radiation Therapy

Chiropractic Services

Colonoscopy (For Medical Reasons)Diagnostic Services - Basic labs/x-rays (related to office visit, LabCorp, etc.) Deductible, Plan pays 100% Deductible, Plan pays 60% of

allowed amount

Diagnostic Services - Major (Facility Charges) (MRI, CT, PET, Nuclear Medicine,etc.)

Diagnostic Services - Major (Physician Charges) (MRI, CT, PET, Nuclear Medicine,etc.) Deductible, Plan pays 100% Deductible, Plan pays 60% of

allowed amount

Diagnostic Services - Minor (Facility Charges) (ultrasounds, bone density, ecography,etc)

Diagnostic Services - Minor (Physician Charges) (ultrasounds, bone density, ecography,etc) Deductible, Plan pays 100% Deductible, Plan pays 60% of

allowed amount

Diabetic Education

Dialysis

Insurance Staffers

Basic Minimum Value (Basic MVP) & Preventative Services Coverage PlanSchedule of Medical Benefits

Option ID: INS9F

This Plan provides Minimal Value Coverage for Medical Care.


* Pre-Certification: Arizona Foundation - FoundationUM (AZF) 833-291-2519

PPO Provider Network:

Physicians: PHCS- Specific Services Network

Facilities: 150% of Medicare

Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination.Minimum weekly hours for full time: 30 hours/130 per month

Benefit Limits Per Calendar Year

All benefits and accumulations are on a calendar year.

Beginning on January 1 and ending on December 31

Plan pays 100% once Deductible is met for in-network providers.

Wellness Care includes, but not limited to: pap smear, mammogram, prostate screening, gynecological exam, routine physical exam, routine vision screening for children, routine hearing screening for children, immunizations and related laboratory blood tests, colonoscopies. Other preventive services as identified by the Patient Protection and Affordable Care Act (PPACA) will be covered. Covered services incurred at a facility will be allowed at the Data iSight amount.

No Benefit

Plan pays 100% One per delivery. Purchase Breast Pump at a local retail store and submit the receipt for reimbursement

Deductible, Plan pays 100% up to 150% of Medicare allowed amount


No Benefit

No Benefit

No Benefit

No Benefit





No Benefit

No Benefit

Durable Medical Equipment (includes orthotics & prosthetics)

Emergency Room Facilities

Emergency Room - All covered services other than facility charges Plan pays 100% Plan pays 100% of allowed

amount

Gastric Bypass Surgery / Lap Banding

Home Health Care

Hospice Care

* Hospital Facility and Inpatient Services

Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement Deductible, plan pays 100% Deductible, Plan pays 60% of

allowed amount

Hospital - Outpatient Services (any charge billed from a hospital)

Infertility Services

Maternity - Prenatal Office Visits Only (billed separately from total delivery) Plan pays 100% No Benefit

Maternity (Labs, x-rays, ultrasounds and related covered services) Deductible, Plan pays 100% Deductible, Plan pays 60% of

allowed amount

* Maternity - Facility and Inpatient Services

Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement Deductible, Plan pays 100% Deductible, Plan pays 60% of

allowed amount

Medical Supplies (Including but not limited to: Insulin, Diabetic test strips, Insulin pumps, etc.) These supplies may also be covered under Prescription Benefit.

* Mental Health - Inpatient

Mental Health Inpatient - All covered services other than facility charges Deductible, Plan pays 100% Deductible, Plan pays 60% of

allowed amount

Mental Health - OutpatientOutpatient TherapyPhysical, Speech and Occupational

Outpatient Surgery performed in an office or urgent care facility

Included with office visit or urgent care Co-pay


Skilled Nursing

Sleep Studies

Sterilization for Women Plan pays 100% Deductible, Plan pays 60% of allowed amount

Sterilization for Men

TMJ and Orthognathic

* Transplant Facility

Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement Deductible, Plan pays 100% Deductible, Plan pays 60% of

allowed amount

Urgent Care Center & 24 Hour Clinic $70 Co-pay, Plan pays 60% Deductible, Plan pays 60% of allowed amount



Pre-Auth Line: 1-844-265-1719

Rx Bin:610011

Rx PCN: IRX

Rx GROUP: FH2FHTT




No Benefit

No Benefit



No Benefit

No Benefit

No Benefit



No Benefit

No Benefit

Prenatal office visit is covered for all females covered under the plan



Percertifiation required if stay is in excess of 48 hours (or 96 hours)

No Benefit



No Benefit

No Benefit

Maximum of $300 per visit

No Benefit

No Benefit

No Benefit

No Benefit


Transplant Services Limited to Inpatient hospitalization only** Patient may be balance billed if provider does not accept 150%

of Medicare Allowable Payment




Sherpaa

All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a guarantee of payment.


Rural Area is defined as 30 miles. If covered services are not available in the network within 30 miles the provider No Pre-existing for employees or dependents. Out of Country services will be paid as a in-network for covered medical emergencies only, to a maximum of $15,000 of billed charges.We believe this coverage is a non grandfathered health plan under the Patient Protection and Affordable

Care Act. (PPACA)


Telemedicine

Plan pays 100% Go to www.sherpaa.com for more information.Effective: 1/1/2019


** Payment will be capped at 150% of the Medicare Allowable Payment. If provider does not accept the Medicare Allowable Amount, patient may

be balance billed.

Note: Any non-allowed or not covered amounts or services are the responsibility of the patient and are not included in the Out-of-Pocket Maximum.Dependents are covered to age 26 regardless of student or marital status.Timely Filing - Claims must be filed within 6 months from the date of service. Coordination of benefits - Non duplicating meaning this Plan will not pay in excess of the normal plan benefit in absence of other insurance.










2019 Temporary Employee Benefits Package Medical Insurance … benefits... · 2019 Temporary...

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