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CHOOSE YOUR MEDICAL COVERAGE OPEN ENROLLMENT 2016 Deseret Premier, Deseret Select, Deseret Value, Deseret Protect It’s open enrollment—time to think about the generous, yet affordable, 2016 medical coverage made available to you by your employer. Please keep in mind all Deseret Mutual plans are preferred provider organizations or PPOs. This means to receive your maximum benefits—and lower your out-of-pocket costs—you must receive services from providers contracted for your specific plan. For 2016, your employer has made Deseret Premier available for the first time in Utah and Southeastern Idaho. This high-option national plan, replacing Deseret Choice, is more portable and goes almost anywhere you do. A modest out-of-network deductible applies, but if you do need to see an out-of-network provider, Deseret Premier still pays 80% after you’ve met the plan deductible. UTID With this and a few other changes described below, choosing a medical plan can be a little daunting. To help you navigate this unfamiliar landscape, we’ve created simple summaries of the employer-sponsored plans available to you. You also have available to you a Notice of Change that specifically details all changes for 2016. Be sure to review that notice as well as this medical plan comparison to make the most informed choices for you and your family. If you are currently a Deseret Choice participant you must select another plan that best meets your needs. If you do not act, your 2016 plan will be Deseret Premier. DESERET PREMIER Generally, Deseret Premier covers primary care—like office visits—at 100% after your $15 copayment to a contracted primary care physician or your $25 copayment to a contracted specialist. Most other services are covered at 90%; you’re responsible for the remaining 10%. When you receive services from Deseret Premier contracted providers, certain preventive services will be covered at 100%, such as colonoscopies, mammograms, physical exams, and well-child care. Limitations do apply; see the preventive services section of your handbook for details. To be eligible for benefits, you or your physician must preauthorize some services with Deseret Mutual, such as surgery and home healthcare. For some services, such as surgery and physical therapy, you must satisfy an annual deductible if you receive care from non-contracted providers ($300 per person or $600 per family). DESERET SELECT Generally, Deseret Select includes hospitals and doctors affiliated with Intermountain Healthcare. Deseret Select covers primary care—such as office visits—at 100% after your $15 copayment to a contracted physician or your $25 copayment to a contracted specialist. Most other services are covered at 90%; you’re responsible for the remaining 10%. When you receive services from Deseret Select contracted providers, certain preventive services will be covered at 100%, such as mammograms, colonoscopies, and well-child care. Limitations do apply; see the preventive services section of your handbook for details. New for 2016, Deseret Select will cover services from non-contracted providers at 60%. You’re responsible for the remaining 40%. To be eligible for benefits, you or your physician must preauthorize some services with Deseret Mutual, such as surgery and home healthcare. DESERET VALUE Generally, Deseret Value covers primary care—such as office visits—at 100% after your $15 copayment to a contracted primary care physician or your $25 copayment to a contracted specialist. Most other services are covered at 70%; you’re responsible for the remaining 30%. When you receive services from Deseret Value contracted providers, certain preventive services are covered at 100%, such as colonoscopies, mammograms, physical exams, and well-child care. Limitations do apply; see the preventive services section of your handbook for details. To be eligible for benefits, you or your physician must preauthorize some services with Deseret Mutual, such as surgery and home healthcare. For some services, such as surgery and physical therapy, you must satisfy an annual deductible if you receive care from non-contracted providers ($300 per person or $600 per family). DESERET PROTECT Deseret Protect has an annual deductible that applies to all major medical expenses, such as surgeries and inpatient hospitalizations ($1,000 per person or $2,000 per family for services from contracted Deseret Protect providers; $1,300 per person or $2,600 per family for non-contracted providers). Generally, Deseret Protect covers primary medical care—such as office visits—at 100% after your $15 copayment to a contracted primary care physician or your $30 copayment to a contracted specialist. The plan covers most other medical services after your deductible at 70%. You’re responsible for the remaining 30%. To be eligible for benefits, you or your physician must preauthorize some services with Deseret Mutual, such as surgery and home healthcare. When you receive services from Deseret Protect contracted providers, certain preventive services are covered at 100%, such as colonoscopies, mammograms, physical exams, and well-child care. Limitations do apply; see the preventive services section of your handbook for details. Deseret Protect prescription coverage is limited primarily to generic medications. Due to Deseret Protect’s low premiums, some services are not covered. These include acupuncture, allergy testing and injections, eye exams, high-cost injections, lifestyle screenings, and obesity surgery. Also, Deseret Protect has a narrower prescription drug formulary. This means many of the medications covered by other Deseret Mutual plans may not be covered by Deseret Protect. THINGS TO REMEMBER All Deseret Premier, Deseret Value, Deseret Protect, and Deseret Select benefits are subject to the maximum allowable limits determined by Deseret Mutual. Receiving care from contracted providers for your specific Deseret Mutual plan protects you financially. Contracted providers accept what you pay (your copayments and coinsurance) and what Deseret Mutual pays as payment in full for eligible services. They won’t bill you for amounts exceeding the maximum allowable limits. For example, if your physician charges $100 for an office visit but the Deseret Mutual maximum allowable amount is $80, he or she won’t bill you for the remaining $20. When you receive care from non-contracted providers, those providers can bill you for the difference. For information about Deseret Mutual contracted providers in your area, visit www. dmba.com. Deseret Mutual offers the most comprehensive access to contracted hospitals of any health plan organization along the Wasatch Front. This includes multiple hospital networks such as Intermountain Healthcare (Intermountain Medical Center), the University of Utah (University Hospital), Iasis (Salt Lake Regional and Jordan Valley hospitals), and MountainStar (St. Mark’s and Ogden Regional hospitals). Remember, the provider networks vary from plan to plan. In choosing your coverage, make sure to check providers who are contracted for your specific plan. Visit our website at www.dmba.com for information about contracted providers in your area. We’re contracted nationally with UnitedHealthcare’s Options PPO network to provide you coverage when you’re out of your service area. If you travel out of the Deseret Mutual service area and need medical care, you can take advantage of UnitedHealthcare’s discounts and be protected from paying charges that exceed our maximum allowable limits. At Deseret Mutual, we’ve decided to maintain the benefit structure that was in place at the time the Patient Protection and Affordable Care Act passed. So Deseret Mutual health plans are considered “grandfathered” under the law. As a grandfathered plan, your coverage may not include certain consumer protections included in the law that apply to other plans. For example, healthcare reform says all preventive health services must be covered at no cost to you, the employee. Grandfathered plans must comply with other consumer protections included in the Affordable Care Act—like eliminating lifetime limits on essential benefits, which Deseret Mutual has already done. For questions about which protections apply and do not apply, as well as information about what could cause a plan to change from grandfathered to non-grandfathered status, please contact us. Or you’re welcome to contact the Employee Benefits Security Administration, U.S. Department of Labor, at 866-444-3272 or www.dol. gov/ebsa/healthreform. FOR MORE INFORMATION Remember, this comparison only points out highlights and important differences you should consider when choosing your coverage. Go to www.dmba.com for more detailed information about Deseret Mutual’s health plans. If you have questions about this information, please call: Deseret Mutual Salt Lake City area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-578-5600 Toll free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-777-3622 We have made every effort to accurately describe the benefits and ensure that information given to you is consistent with other benefit-related communications. However, if there is any discrepancy or conflict between information in this document and other plan materials, the terms outlined in the Legal Plan Document will govern. You can view the Summary Plan Description (benefits handbook) by logging into www.dmba.com. DESERET PREMIER à SUMMARY OF BENEFITS AVAILABLE HOSPITALS IN PLAN Juab Salt Lake Sanpete Summit Tooele Utah Wasatch Weber Bannock Bear Lake Bingham UTAH Bear River Valley Hospital Brigham City Community Hospital Davis Hospital & Medical Center Lakeview Hospital Central Valley Medical Center Alta View Hospital Intermountain Medical Center Orthopedic Specialty Hospital LDS Hospital Lone Peak Hospital Riverton Hospital Primary Children’s Medical Center Huntsman Cancer Hospital Jordan Valley Hospital Pioneer Valley Hospital Salt Lake Regional Medical Center St. Mark’s Hospital University Hospital Gunnison Valley Hospital Sanpete Valley Hospital Park City Medical Center Mountain West Medical Center American Fork Hospital Orem Community Hospital Utah Valley Regional Medical Ctr. Mountain Point Medical Center Mountain View Hospital Timpanogos Regional Hospital Heber Valley Medical Center McKay-Dee Hospital Ogden Regional Medical Center IDAHO Portneuf Medical Center Bear Lake Memorial Hospital Bingham Memorial Hospital Idaho Doctors' Hospital Bonneville Eastern Idaho Regional Medical Center Mountain View Hospital Caribou Caribou Memorial Hospital Cassia Cassia Regional Medical Center Franklin Franklin County Medical Center Madison Madison Memorial Hospital Oneida Oneida County Hospital Power Harms Memorial Teton Teton Valley Hospital * Preauthorization may be required for these services. If you do not preauthorize with Deseret Mutual, you must pay up to the first $200 per service. Annual deductible does not apply Davis Physician Services: Office Visits Physician Services: Routine Adult Physicals Well-Child Care Well-Woman Care Routine Eye Exams Outpatient Mental Health Therapy Outpatient Laboratory WHAT YOU PAY Deseret Premier PCP: $15 per visit Deseret Premier specialist: $25 per visit Non-Deseret Premier PCP: $20 per visit Non-Deseret Premier specialist: $30 per visit Deseret Premier PCP: Nothing Deseret Premier specialist: Nothing Non-Deseret Premier PCP: $20 per visit Non-Deseret Premier specialist: $30 per visit Routine physical and well-woman exams are eligible once per calendar year. No limits on well-child care. Deseret Premier provider: $25 per visit Non-Deseret Premier provider: $30 per visit One exam is covered every calendar year Deseret Premier provider: $15 for individual and group therapy. Non-Deseret Premier provider: $20 for individual and group therapy. Nothing (the plan pays 100%) Prescription Drugs Retail formulary drugs: 30% for 30-day supply Mail-order formulary drugs: 25% for 90-day supply; up to $85 per prescription All non-formulary drugs: 100% (not covered) Basic Radiology Deseret Premier provider: 10% Non-Deseret Premier provider: 20% Hospital Emergency Room Annual deductible applies Box Elder SERVICES $75 per visit plus 10% Inpatient Hospital Services* Deseret Premier provider: 10% Non-Deseret Premier provider: 20% Inpatient Maternity Services Deseret Premier provider: 10% Non-Deseret Premier provider: 20% Inpatient Mental Health Services* Deseret Premier provider: 10% Non-Deseret Premier provider: 20% Major Radiology Services* Deseret Premier provider: 10% Non-Deseret Premier provider: 20% Maternity (Physician) Deseret Premier provider: 10% Non-Deseret Premier provider: 20% Surgery* Physical Therapy Deseret Premier provider: 10% Non-Deseret Premier provider: 20% Deseret Premier provider: $25 per visit Non-Deseret Premier provider: $30 per visit Up to 25 visits per calendar year Chiropractic Therapy Deseret Premier provider: $25 per visit Non-Deseret Premier provider: $30 per visit Up to 25 visits per calendar year Medical Equipment* Deseret Premier provider: 10% Non-Deseret Premier provider: 20% Annual Deductible Your Annual Maximum Out-of-Pocket Cost $300 per person or $600 per family for services from nonnetwork providers. You are responsible for over-maximum allowable amounts when using non-contracted providers. $2,000 per person or $4,000 per family. Then the plan pays 100% of eligible charges. The annual deductible does not apply. Copayments still apply after the out-of-pocket maximum is met. DESERET SELECT à AVAILABLE HOSPITALS IN PLAN Box Elder Davis Juab Salt Lake Sanpete Summit Tooele Utah Wasatch Weber Bannock Bear Lake Bingham UTAH Bear River Valley Hospital ... Davis Hospital & Medical Center ... Central Valley Medical Center Alta View Hospital Intermountain Medical Center Orthopedic Specialty Hospital LDS Hospital ... Riverton Hospital Primary Children’s Medical Center ... ... ... ... ... ... Gunnison Valley Hospital Sanpete Valley Hospital Park City Medical Center Mountain West Medical Center American Fork Hospital Orem Community Hospital Utah Valley Regional Medical Ctr. ... ... ... Heber Valley Medical Center McKay-Dee Hospital ... IDAHO Portneuf Medical Center Bear Lake Memorial Hospital Bingham Memorial Hospital Idaho Doctors' Hospital Bonneville Eastern Idaho Regional Medical Center ... Caribou Caribou Memorial Hospital Cassia Cassia Regional Medical Center Franklin Franklin County Medical Center Madison Oneida Power Teton Madison Memorial Hospital Oneida County Hospital Harms Memorial Teton Valley Hospital * Preauthorization may be required for these services. If you do not preauthorize with Deseret Mutual, you must pay up to the first $200 per service. Non-contracted providers can charge over maximum allowable limits. You are responsible for over-maximum allowable amounts when using non-contracted providers. SUMMARY OF BENEFITS SERVICES Physician Services: Office Visits Physician Services: Routine Adult Physicals Well-Child Care Well-Woman Care WHAT YOU PAY Deseret Select PCP: $15 per visit Deseret Select specialist: $25 per visit Non-Deseret Select PCP: $25 per visit Non-Deseret Select Specialist: $35 per visit Deseret Select PCP: Nothing Deseret Select specialist: Nothing Non-Deseret Select PCP: $25 Non-Deseret Select Specialist: $35 Routine physical and well-woman exams are eligible once per calendar year. No limits on well-child care. Routine Eye Exams Deseret Select provider: $25 per visit Non-Deseret Select provider: $35 One exam is covered every calendar year Outpatient Mental Health Deseret Select provider: $15 for individual and group Therapy therapy Non-Deseret Select provider: $25 Outpatient Laboratory Nothing (the plan pays 100%) Prescription Drugs Retail formulary drugs: 30% for 30-day supply Mail-order formulary drugs: 25% for 90-day supply; up to $85 per prescription All non-formulary drugs: 100% (not covered) Basic Radiology Deseret Select provider: 10% Non-Deseret Select provider: 40% Hospital Emergency Room $75 per visit plus 10% Inpatient Hospital Services* Deseret Select provider: 10% Non-Deseret Select provider: 40% Inpatient Maternity Services Deseret Select provider: 10% Non-Deseret Select provider: 40% Inpatient Mental Health Services* Deseret Select provider: 10% Non-Deseret Select provider: 40% Major Radiology Services* Deseret Select provider: 10% Non-Deseret Select provider: 40% Surgery* Deseret Select provider: 10% Non-Deseret Select provider: 40% Maternity (Physician) Deseret Select provider: 10% Non-Deseret Select provider: 40% Physical Therapy Deseret Select provider: $25 per visit Non-Deseret Select provider: $35 per visit Up to 25 visits per calendar year Chiropractic Therapy CHP provider: $25 per visit; no visit limit when preauthorized and medically necessary Non-CHP provider: $35 per visit; up to five visits per year Medical Equipment* Deseret Select provider: 10% Non-Deseret Select provider: 40% $2,000 per person or $4,000 per family for services from Deseret Select providers. $4,000 per person or $8,000 per family for non-Deseret Select providers. Then the plan pays 100% of eligible charges. Copayments still apply after the out-of-pocket maximum is met. The annual deductible does not apply. Your Annual Maximum Out-of-Pocket Cost DESERET VALUE à SUMMARY OF BENEFITS AVAILABLE HOSPITALS IN PLAN Juab Salt Lake Sanpete Summit Tooele Utah Wasatch Weber Bannock Bear Lake Bingham UTAH Bear River Valley Hospital Brigham City Community Hospital Davis Hospital & Medical Center Lakeview Hospital Central Valley Medical Center Alta View Hospital Intermountain Medical Center Orthopedic Specialty Hospital LDS Hospital Lone Peak Hospital Riverton Hospital Primary Children’s Medical Center Huntsman Cancer Hospital Jordan Valley Hospital Pioneer Valley Hospital Salt Lake Regional Medical Center St. Mark’s Hospital University Hospital Gunnison Valley Hospital Sanpete Valley Hospital Park City Medical Center Mountain West Medical Center American Fork Hospital Orem Community Hospital Utah Valley Regional Medical Ctr. Mountain Point Medical Center Mountain View Hospital Timpanogos Regional Hospital Heber Valley Medical Center McKay-Dee Hospital Ogden Regional Medical Center IDAHO Portneuf Medical Center Bear Lake Memorial Hospital Bingham Memorial Hospital Idaho Doctors' Hospital Bonneville Eastern Idaho Regional Medical Center Mountain View Hospital Caribou Caribou Memorial Hospital Cassia Cassia Regional Medical Center Franklin Franklin County Medical Center Madison Madison Memorial Hospital Oneida Oneida County Hospital Power Harms Memorial Teton Teton Valley Hospital * Preauthorization may be required for these services. If you do not preauthorize with Deseret Mutual, you must pay up to the first $200 per service. Annual deductible does not apply Davis Physician Services: Office Visits Physician Services: Routine Adult Physicals Well-Child Care Well-Woman Care Routine Eye Exams Outpatient Mental Health Therapy Outpatient Laboratory WHAT YOU PAY Deseret Value PCP: $15 per visit Deseret Value specialist: $25 per visit Non-Deseret Value PCP: $20 per visit Non-Deseret Value specialist: $30 per visit Deseret Value PCP: Nothing Deseret Value specialist: Nothing Non-Deseret Value PCP: $20 per visit Non-Deseret Value specialist: $30 per visit Routine physical and well-woman exams are eligible once per calendar year. No limits on well-child care. Deseret Value provider: $25 per visit Non-Deseret Value provider: $30 per visit One exam is covered every calendar year Deseret Value provider: $15 for individual and group therapy. Non-Deseret Value provider: $20 for individual and group therapy Nothing (the plan pays 100%) Prescription Drugs Retail formulary drugs: 50% for 30-day supply. Mail-order formulary drugs: 45% for 90-day supply; up to $140 per prescription All non-formulary drugs: 100% (not covered) Basic Radiology Deseret Value provider: 30% Non-Deseret Value provider: 40% Hospital Emergency Room Annual deductible applies Box Elder SERVICES $75 per visit plus 30% Inpatient Hospital Services* Deseret Value provider: 30% Non-Deseret Value provider: 40% Inpatient Maternity Services Deseret Value provider: 30% Non-Deseret Value provider: 40% Inpatient Mental Health Services* Deseret Value provider: 30% Non-Deseret Value provider: 40% Major Radiology Services* Deseret Value provider: 30% Non-Deseret Value provider: 40% Maternity (Physician) Deseret Value provider: 30% Non-Deseret Value provider: 40% Surgery* Physical Therapy Deseret Value provider: 30% Non-Deseret Value provider: 40% Deseret Value provider: $25 per visit Non-Deseret Value provider: $30 per visit Up to 25 visits per calendar year Chiropractic Therapy Deseret Value provider: $25 per visit Non-Deseret Value provider: $30 per visit Up to 25 visits per calendar year Medical Equipment* Deseret Value provider: 30% Non-Deseret Value provider: 40% Annual Deductible $300 person or $600 per family for services from nonnetwork providers. You are responsible for over-maximum allowable amounts when using non-contracted providers. Your Annual Maximum Out-of-Pocket Cost $4,000 per person or $6,000 per family. Then the plan pays 100% of eligible charges. The annual deductible does not apply. Copayments still apply after the out-of-pocket maximum is met. DESERET PROTECT à SUMMARY OF BENEFITS AVAILABLE HOSPITALS IN PLAN Juab Salt Lake Sanpete Summit Tooele Utah Wasatch Weber Bannock Bear Lake Bingham UTAH Bear River Valley Hospital Brigham City Community Hospital Davis Hospital & Medical Center Lakeview Hospital Central Valley Medical Center Alta View Hospital Intermountain Medical Center Orthopedic Specialty Hospital LDS Hospital Lone Peak Hospital Riverton Hospital Primary Children’s Medical Center Huntsman Cancer Hospital Jordan Valley Hospital Pioneer Valley Hospital Salt Lake Regional Medical Center St. Mark’s Hospital University Hospital Gunnison Valley Hospital Sanpete Valley Hospital Park City Medical Center Mountain West Medical Center American Fork Hospital Orem Community Hospital Utah Valley Regional Medical Ctr. Mountain Point Medical Center Mountain View Hospital Timpanogos Regional Hospital Heber Valley Medical Center McKay-Dee Hospital Ogden Regional Medical Center IDAHO Portneuf Medical Center Bear Lake Memorial Hospital Bingham Memorial Hospital Idaho Doctors' Hospital Bonneville Eastern Idaho Regional Medical Center Mountain View Hospital Caribou Caribou Memorial Hospital Cassia Cassia Regional Medical Center Franklin Franklin County Medical Center Madison Oneida Power Teton Madison Memorial Hospital Oneida County Hospital Harms Memorial Teton Valley Hospital * Preauthorization may be required for these services. If you do not preauthorize with Deseret Mutual, you must pay up to the first $200 per service. ** Copayments DO NOT apply toward the annual deductible. Annual deductible does not apply Davis Physician Services: Office Visits Annual deductible applies ** Box Elder SERVICES Physician Services: Routine Adult Physicals Well-Child Care Well-Woman Care Routine Eye Exams WHAT YOU PAY Deseret Protect PCP: $15 per visit Deseret Protect specialist: $30 per visit Non-Deseret Protect PCP: $20 per visit Non-Deseret Protect specialist: $35 per visit Deseret Protect PCP: Nothing Deseret Protect specialist: Nothing Non-Deseret Protect PCP: $20 per visit Non-Deseret Protect specialist: $35 per visit Routine physical and well-woman exams are eligible once per calendar year. No limits on well-child care. 100% (not covered) Outpatient Mental Health Deseret Protect provider: $15 for individual and group Therapy therapy Non-Deseret Protect provider: $20 for individual and group therapy Outpatient Laboratory Nothing (the plan pays 100%) Prescription Drugs Generic drugs: 20% for retail and mail-service (limited list of generic drugs) Brand-name drugs: 50% for retail and mail service (very limited list of brand-name drugs) Basic Radiology Deseret Protect provider: 30% Non-Deseret Protect provider: 40% Hospital Emergency Room $75 per visit plus 30% Inpatient Hospital Services* Deseret Protect provider: 30% Non-Deseret Protect provider: 40% Inpatient Maternity Services Deseret Protect provider: 30% Non-Deseret Protect provider: 40% Inpatient Mental Health Services* Deseret Protect provider: 30% Non-Deseret Protect provider: 40% Major Radiology Services* Deseret Protect provider: 30% Non-Deseret Protect provider: 40% Surgery* Deseret Protect provider: 30% Non-Deseret Protect provider: 40% Maternity (Physician) Deseret Protect provider: 30% Non-Deseret Protect provider: 40% Physical Therapy Deseret Protect provider: $30 per visit Non-Deseret Protect provider: $35 per visit Up to 15 visits per calendar year Chiropractic Therapy Deseret Protect provider: $30 per visit Non-Deseret Protect provider: $35 per visit Up to 15 visits per calendar year Medical Equipment* All providers 50% Annual Deductible Your Annual Maximum Out-of-Pocket Cost $1,000/person, $2,000/family for network providers; $1,300/person, $2,600/family for non-network. You are responsible for over-maximum allowable amounts when using non-contracted providers. $4,000 per person or $6,000 per family. Then the plan pays 100% of eligible charges. The annual deductible does not apply. Copayments still apply after the out-ofpocket maximum is met. NOTES: