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Customer Service

Magellan Pool 2018 Guide

emihealth.com

Toll Free: Local:

800.662.5851 801.262.7475

Magellan Pool Employee Benefits

Offered Through

1

"In the most recent member survey, EMI Health recorded an overall satisfaction ranking of 92 percent with the quality of benefits, network of physicians and facili-ties, fast and accurate claims payments, and customer service."

At EMI Health, we take great pride in the overall quality and excellence of the products and services we offer our individual members and employer groups, as well as the service we provide to our business partners, includ-ing physicians, dentists, medical facilities, and insurance agents.

To ensure that we are meeting the needs of all of these groups, we conduct annual satisfaction surveys of members, providers, and agents. This allows us to fine tune processes and procedures to better serve our clients. One of the greatest measures of our success is the result of these surveys. In the most recent member survey, EMI Health recorded an overall satisfaction ranking of 92 percent with the quality of benefits, network of physicians and facilities, fast and accurate claims payments, and customer service. Providers are highly satisfied as well, giving EMI Health a 95 percent overall satisfaction ranking.

In addition to the recognition of those we work with, EMI Health was also recently honored as Utah's Best of State winner in the Insurance Category for 2014. Best of State is a nonprofit organization that employs an independent volunteer board of business and civic leaders as judges to recognize outstanding individuals, organizations, and businesses in Utah.

Nominees are judged on achievement in their fields, innovation and creativity, and their contribution to improving the quality of life in Utah. We are extremely proud of this achievement and what it says about our commitment to being the very best benefit option for our members.

emihealth.comTM

Quality, Satisfaction, and Excellence

EMI.MKTG.BEST-STATE.0515.0047

WINNER BEST OF STATEfor INSURANCE

UTAH 2012


UTAH 2009


UTAH 2007

1

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852 EAST ARROWHEAD LANE, MURRAY, UTAH 84107TOLL FREE 800 662 5850 CORPORATE 801 262 7476 FAX 801 270 3016

emihealth.com

EMI Health Can Be The One Source For All of Your

Employee Benefits

EMI Health was founded on June 26, 1935, as a teachers welfare organization and has provided health insurance for more than 70 years. Over that time, EMI Health has evolved into a successful health insurance organization serving employer groups in both public and commercial sectors. With no stockholders, EMI Health can use excess earnings to offer members quality health benefits for lower premiums.

EMI Health enjoys a ratio of assets over liabilities that is one of the strongest in the industry and maintains a high ratio of surplus funds to policy reserve liabilities. With premium revenue of over $165 million, EMI Health has the stability to support your insurance needs and the flexibility to address your specific goals with a personal touch.

At EMI Health, we take great pride in the overall quality and excellence of the products and services we offer our individual members and employer groups, as well as the service we provide to our business partners. In our most recent member survey, EMI Health recorded an overall satisfaction ranking of 92 percent, with high satisfaction in quality of benefits, network of physicians and facili-ties, fast and accurate claims payments, and customer service. Providers are highly satisfied as well, giving EMI Health a 95 percent overall satisfaction ranking. EMI Health was also recently honored as Utah's Best of State winner in the Insurance Category for 2012, with prior Best of State awards in 2007 and 2009.

VisionProviderNetwork

DentalCustomer

Service

Medical &

COBRAPools

Wellness

3

Medical BenefitsEMI Health offers a full range of fully

insured and self-funded medical plans.

Nine self-funded benefit options have

been created for the Utah Credit Union

Pool which offers a wide range of op-

tions to individuals employer groups.

Please refer to the medical section of

the cost proposal for more information.

COBRA AdministrationEMI Health provides full COBRA

administration at no additional cost for

members electing the medical plan.

Dental BenefitsEMI Health provides comprehensive

dental benefit plans with access to over

2,000 participating providers in Utah.

Nationwide networks includes TDA,

DenteMax, and Careington.

Voluntary and contributory, copay and

traditional PPO plan offerings are avail-

able.

In addition to the dental options above,

the Choice Dental Plan offers a

coinsurance product that uses both

the Advantage and Premier networks.

The Advantage network offers a richer

benefit (lower deductible and coinsur-

ance, plus a higher annual maximum)

as well as the flexibility of the broader

Premier network.

Vision BenefitA primary vision care benefit is an

important part of an organization's

overall wellness package. Eye exams

are a vital part of evaluating and

maintaining health of eyes and can

detect general health conditions such

as diabetes, high blood pressure, and

glaucoma.

EMI Health's Vision Plans give

members the freedom to choose any

provider, one eye exam per year, and

one pair of hardware glasses every

24 months.

Wellness WebThe Wellness Web, which is

accessible through EMI Health

website, allows members to

increase their health knowledge by

researching symptoms, connecting

with support groups, and linking

directly to valuable websites such as

The American Heart Association and

the U.S. Department of Health. Please

see the Wellness portion of this packet

for more information.

Provider NetworkEMI Health uses the Care Plus Network

for all employees in Utah. Nationally

the CIGNA PPO network is available for

those that are traveling or live outside

of Utah.

4


emihealth.com

Customer ServiceEMI Health provides excellent levels of customer service and support.

• Telephone customer service from 8:00 a.m. to 6:00 p.m. Mountain Time,

Monday through Friday. Customer service representatives have instant

access to all claims, enrollment forms, and benefit summaries for

accurate handling of every call.

• Toll-free phone number is 1(800) 662-5852

• Each group is assigned a dedicated team of customer service representatives

and claims editors.

• The new Electronic Explanation of Benefits allows members to access

claims history online and receive claim notifications via email. EMI Health

uses the latest encryption technologies to secure private information.

• The online enrollment system allows members to make changes to

eligibility, update personal information, enter family status changes,

and view claims status and history.

PoolingPools offer several advantages over traditional single-group coverage:

• Minimized risk

• Easier to budget

• Easier to predict increases and decreases

• Keeps renewal rates at a minimum

• Underwritten as a large self-funded group

• Provides a forum for discussion

• Meet on a quarterly or semi-annual basis

A self-funded pool has particular advantage in light of current Health Care Reform

requirements. Under the Utah Credit Union Pool a group will be able to have insurance

rates based on their particular demographics and claims experience rather than the

overall state average. Estimates vary, but small group fully-insured premiums could

increase by as much as 50% for some groups. Self-funded groups can avoid much of

these increases and can save as much as $10 per member per month in just fees and

taxes. In addition as part of the pool, groups will have the opportunity to assist in the

management of their plan including review claims experience and utilization patterns

and discuss plan design changes.

5

Minimized risk Easier to budget

Easier to predict increases and decreases

Lower administrative costs

Underwritten as a self-funded group

Provides quarterly pool reports

Significant cost and benefit design advantages in relation

to current health care reform requirements

Keeps renewal rates at a minimum

Risk tiers Provides appropriate tiering for each group to keep

pool strong for all risk.

Benefits all risk type groups

Clean Pool Minimal subsidization due to risk tiers

As the pool grows, it can accept or reject new

groups based on their risk

Forum Representative from each group will meet quarterly

Voting rights for renewal changes

Voting rights for accepting new groups to pool

Exclusive network with excellent access Better discounts

Three year pool commitment One month deposit of premium or $3500, whichever

is greater

Provides stability and integrity to the pool


emihealth.com

Why Participate in an EMI Health Pool?

EMI Health can provide a unique way of coming together and pooling your health plan.

This will provide you and your employees with low renewals and better cost control.

6


emihealth.com

EMI Health's Value Added Services

TeleMedicineEMI TeleMed is designed to provide our members with access to doctors across the nation 24/7 365 days of the year. Speak with a doctor anytime and pay no consultation fee. You can save time and money on office visits, urgent care visits, and emergency room visits.

EMI TeleMed, in partnership with WellVia, gives you access to a U.S. board-certified doctor over the phone anytime, anywhere.

The WellVia physician network: ¥ U.S. based and licensed ¥ Primary care, pediatricians, and board-certified specialists ¥ Average 10 years of experience ¥ Supported by internal, bilingual Patient Care Center ¥ Specialists in communicating and diagnosing via TeleMed

Some 70% of all doctor visits can be handled over the phone and 40% of urgent care visits can be manged using TeleMed.

EMI TeleMed doesn't replace your primary care physician. It is a convenient, alternative way for you to get the care you need that will save you time and money. Whether it's the middle of the night, while you're on vacation, on a business trip, or that moment when you've run out of a prescription, WellVia is on call.

Common Conditions * Acid Reflux * Asthma * Cold & Flu * Diabetes * Headache * Sore Throat * Many Other Conditions

Medications Prescribed * Albuteral * Allegra * Flonase * Ibuprofen 800mg * Levaquin * Lipitor * Nasonex * Many Other Medications

7


emihealth.com

Wellness ProgramEMI Health has a deep concern for the wellbeing of our members. This program is designed to provide real value in areas that have been proven to make a difference:

Biometric ScreeningTrained screeners run a series of tests at the employer's site and participants receive instant feedback.

Mobile MammogramTrained professionals come to the employer's location to perform screenings using state-of-the-art equipment.

Flu Shot ClinicImmunization-trained pharmacists or clinical practitioners come to a location of the employer's choosing.

Wellness CoachingCertified Health and Wellness Coaches check in with your employees to offer support, motivation, and accountability to personal wellness goals.

Minimum participation numbers apply for screenings, mobile mammograms, and flu clinics.

Case and Disease ManagementEMI Health's care management program, in partnership with Veridicus Care Management, integrates programs across the care continuum with a collaborative team approach. Integration unites different viewpoints and allows management of every aspect of patient care.

Nurse Care Manager ¥ Supports and advocates for patients helping them navigate the healthcare system and obtain appropriate care

Pharmacist Care Manager ¥ Approaches care from a treatment-based perspective focused on disease and drug information

Mental Health Care Manager ¥ Incorporates social and behavioral components of care

This program works to ensure that patients with complex medical needs receive care in a cost effective and timely manner. Our team of healthcare professionals work together to achieve better patient outcomes and cost savings to both the patient and the health plan.

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8

Use WellVia ForCommon Conditions

• Acid Reflux• Asthma

• Cold & Flu• Diabetes

• Headache•High Blood Pressure

• Sinus Conditions• Sore Throat

Many Other Conditions

• U.S. based and licensed• Primary Care, Pediatricians and

Board-Certified Specialists• Average 10 Years of Experience• Supported by internal, bilingual

Patient Care Center• Specialists in communicating and

diagnosing via Telehealth

WellVia doesn’t replace your primary care physician. It is a convenient, alternative way for you to get the care you need that will save you time and money. Whether it’s the middle of the night, while you’re on vacation, on a business trip, or that moment when you’ve run out of a prescription, WellVia is on call.

WellVia forEMI Health gives you access to a U.S. board-certified doctor over the phone anytime, anywhere. Some 70% of all doctor visits can be handled over the phone, and 40% of urgent care visits can be managed using Telehealth.

Get MedicationsPrescribed

Trust OurPhysician Network

• Albuteral• Allegra• Flonase

• Ibuprofen 800mg• Levaquin

• Lipitor• Metaform

• NasonexMany Other Medications

Now You Can Talk To A Doctor

Speak with a doctor anytime and pay no consultation fee.

Days Of The Year

WellViaSolutions.com Patient Care Center: 1-877-872-0370

1-877-872-0370

9

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emihealth.com

Finding Participating Providers

Using participating providers is an important part of ensuring that you make the most of your health plan benefits. You can confirm that your provider is part of the EMI Health network, or locate a new participating provider, online at emihealth.com:

1. Click on the "Provider Search" link on the left-hand side of the page.

2. Select the type of network (medical, dental, or vision).

3. Select your plan (as identified on your ID card) and your state.

4. To narrow your search, select one or more of the additional criteria listed.

5. Click "Search."

Not all plans have participating provider benefits outside of your state of residence. To confirm your benefits, or if you have any questions, please contact EMI Health's customer service department toll free at 800.662.5851.

10


emihealth.com

EMI Health Participating Hospitals

Beaver CountyBeaver Valley Hospital1109 North 100 WestBeaver, UT 84713435-438-7100

Milford Valley Memorial Hospital451 North Main StreetMilford, UT 84751435-387-2411

Box Elder CountyBear River Valley Hospital905 North 1000 WestTremonton, UT 84337435-207-4500

Cache CountyLogan Regional Hospital500 East 1400 NorthLogan, UT 84341

435-716-1000

Carbon CountyCastleview Hospital300 North Hospital DrivePrice, UT 84501435-637-4800

Davis CountyDavis Hopsital and Medical Center1600 West Antelope DriveLayton, UT 84041801-807-1000

Duchesne CountyUintah Basin Medical Center250 West 300 NorthRoosevelt, UT 84066435-722-4691

Garfield CountyGarfield Memorial Hospital200 North 400 EastPanguitch, UT 84759435-676-8811

Grand CountyMoab Regional Hospital450 Williams WayMoab, UT 84532435-259-7191

Iron CountyCedar City Hospital1303 North Main StreetCedar City, UT 84720435-868-5000

Juab CountyCentral Valley Medical Center48 West 1500 NorthNephi, UT 84648435-623-3000

Kane CountyKane County Hospital355 North Main StreetKanab, UT 84741435-644-5811

Millard CountyDelta Community Hospital126 White South Sage AveDelta, UT 84624435-864-5591

Fillmore Community Hospital674 South Highway 99Fillmore, UT 84631435-743-5591

Salt Lake CountyAlta View Hospital9660 South 1300 EastSandy, UT 84094801-501-2600

11

EMI Health Participating Hospitals

Salt Lake County cont.Intermountain Medical Center5121 Cottonwood StreetMurray, UT 84107801-507-7000

John A Moran Eye Center65 Mario Capecchi DriveSalt Lake City, UT 84132801-581-2352

Jon and Karen Huntsman Cancer Center5121 Cottonwood StreetMurray, UT 84107801-507-7000

LDS Hospital8th Ave & C StreetSalt Lake City, UT 84143

801-408-1100

Primary Childrens Hospital100 North Mario Capecchi DriveSalt Lake City UT, 84113801-662-1000

TOSH - The Orthopedic Specialty Hospital5848 South 300 EastMurray, UT 84107801-314-4100

U of U Hospital Burn Center50 North Medical DriveSalt Lake City, UT 84132801-581-2700

Riverton Hospital3741 West 12600 SouthRiverton, UT 84065801-285-4000

San Juan CountyBlue Mountain Hopsital802 South 200 West Ste ABlanding, UT 84511435-678-3992

San Juan Hospital380 West 100 NorthMonticello, UT 84535435-587-5054

Sanpete CountyGunnison Valley Hospital45 East 100 North StreetGunnison, UT 84634435-528-7246

Sanpete Valley Hospital1100 South Medical DriveMount Pleasant, UT 84647435-462-2441

Sevier CountySevier Valley Hospital1000 North Main StreetRichfield, UT 84701435-893-4100

Summit CountyPark City Medical Center900 Round Valley DrivePark City, UT 84060435-658-7000

Tooele CountyMountain West Medical Center2055 North Main StreetTooele, UT 84074435-843-3600

Uintah CountyAshley Valley Medical Center75 North 200 WestVernal, UT 84078435-789-3342

Utah CountyAmerican Fork Hospital170 North 1100 EastAmerican Fork, UT 84003801-855-3300

Orem Community Hospital331 North 400 WestOrem, UT 84057801-224-4080

Utah Valley Hospital1034 North 500 WestProvo, UT 84604801-373-7850

Wasatch CountyHeber Valley Medical Center1485 South Highway 40Heber City, UT 84032435-654-2500

Washington CountyDixie Regional Medical Center1380 East Medical Center DriveSt. George, UT 84790435-251-1000

Weber CountyMcKay Dee Hospital4401 Harrison BlvdOgden, UT 84403801-387-2800


emihealth.com12


emihealth.com

Intermountain InstaCare Facilities

Box Elder CountyBox Elder InstaCare1050 South 500 WestBrigham City, UT 84302435-695-2727M-Sun 8AM-8PM

Cache CountyLogan InstaCare412 North 200 EastLogan, UT 84321435-713-2710M-Sun 8AM-8PM

North Cache Valley InstaCare4088 North Hwy 91Hyde Park, UT 84318435-563-4888M-Sat 8AM-8PM

Davis CountyBountiful InstaCare390 North Main StreetBountiful, UT 84010801-292-6100M-Sun 9AM-9PM

Davis County cont.Kaysville Creekside InstaCare435 North Main StreetKaysville, UT 84037801-498-6000M-F 9AM-9PM Sat-Sun 9AM-5PM

Layton InstaCare2075 University Park Blvd (1200 West)Layton, UT 84041801-779-6200M-F 9AM-9PM Sat-Sun 9AM-6PM

Syracuse InstaCare745 South 2000 WestSyracuse, UT 84075801-525-2410M-F 9AM-9PM Sat-Sun 9AM-3PM

Iron CountyCedar City InstaCare962 Sage DriveCedar City, UT 84720435-865-3440M-Sat 9AM-9PM

Salt Lake CountyCottonwood InstaCare181 East Medical Tower DriveMurray, UT 84107801-314-7700M-Sun 9AM-12AM

Draper Instacare12473 South Minuteman DriveDraper, UT 84020801-495-7970M-Sun 9AM-9PM

Holladay InstaCare6272 South Highland DriveMurray, UT 84121801-871-6400M-Sun 9AM-9PM

Memorial InstaCare2000 South 900 EastSalt Lake City, UT 84105801-464-7777M-Sun 9AM-9PM

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emihealth.com

Intermountain InstaCare Facilities

Salt Lake County cont.North Temple Urgent Care54 North 800 WestSalt Lake City, UT 84116801-408-8654M-Sat 10AM-7PM

Riverton Southridge Instacare3723 West 12600 South #150Riverton, UT 84065801-285-4560M-Sun 9AM-9PM

Salt Lake Clinic InstaCare389 South 900 EastSalt Lake City, UT 84102385-282-2400M-Sun 9AM-9PM

Sandy InstaCare9493 South 700 EastSandy, UT 84070801-576-0176M-Sun 9AM-9PM

Taylorsville InstaCare3845 West 4700 SouthTaylorsville, UT 84118801-840-2020M-Sun 9AM-9PM

West Jordan InstaCare2655 West 9000 SouthWest Jordan, UT 84088801-256-6399M-Sun 9AM-9PM

Summit CountyPark City Bonanza InstaCare1665 Bonanza DrivePark City, UT 84068435-649-7640M-Sun 8AM-8PM

Tooele CountyTooele InstaCare777 North Main StreetTooele, UT 84074435-228-1200M-Sun 9AM-9PM

Utah CountyAmerican Fork InstaCare98 North 1100 East Ste 101American Fork, UT 84003801-492-2550M-Sun 8AM-8PM

North Orem InstaCare1975 North State StreetOrem, UT 84057801-714-5000M-Sun 8AM-10PM

Payson InstaCare854 South Turf Farm Road Ste 1Payson, UT 84651801-465-6250M-Sun 8AM-8PM

Provo InstaCare1134 North 500 West Ste 102Provo, UT 84604801-357-1770M-Sun 9AM-9PM

Saratoga Spings InstaCare354 West State Rd 73Saratoga Springs, UT 84045801-341-5200M-Sun 8AM-8PM

Springville InstaCare762 West 400 SouthSpringville, UT 84663801-429-1250M-Sun 8AM-8PM

Washington CountyHurricane Valley InstaCare75 North 2260 WestHurricane, UT 84737435-635-6550M-Sat 9AM-9PM

St. George-River Road Instacare577 South River RoadSt. George, UT 84790435-688-6300M-Sun 9AM-9PM

St. George-Sunset InstaCare1739 West Sunset BlvdSt. George, UT 84770435-634-6050M-Sat 9AM-9PM

Weber CountyNorth Ogden InstaCare2400 North Washington BlvdNorth Ogden, UT 84414801-786-7500M-Sat 9AM-9PM Sun 9AM-5PM

Roy-Herefordshire InstaCare1915 West 5950 SouthRoy, UT 84067801-387-8282M-Sat 9AM-9PM Sun 1Pm-5pm

South Ogden InstaCare975 East Chambers StreetSouth Ogden, UT 84403801-387-6200M-F 9AM-9PM Sat 9AM-5PM Sun 9AM-1PM

14

Intermountain KidsCare Facilities

Davis CountyBountiful KidsCare390 North Main StreetBountiful, UT 84010801-294-9933M-F 4PM-9PM Sat-Sun 9AM-9PM

Layton KidsCare2075 University Park Blvd (1200 West)Layton, UT 84041801-779-6200M-F 5PM-9PM

Salt Lake CountyRiverton-Southridge KidsCare3723 West 12600 South #150Riverton, UT 84065801-285-4561M-F 4PM-9PM Sat-Sun 9AM-9PM

Salt Lake-Memorial KidsCare2000 South 900 EastSalt Lake City, UT 84105801-464-7788M-F 4PM-9PM Sat-Sun 12PM-9PM

Sandy-Mountain View KidsCare9720 South 1300 East Ste 100Sandy, UT 84094801-571-8550M-F 5PM-10PM Sat-Sun 12PM-9PM

Taylorsville KidsCare3845 West 4700 SouthTaylorsville, UT 84118801-840-2101M-Sun 9AM-9PM

West Jordan KidsCare2655 West 9000 SouthWest Jordan, UT 84088801-568-9933M-F 4PM-9PM Sat-Sun 12PM-9PM

Weber CountyMcKay Dee KidsCare4403 Harrison Blvd Ste 4875Ogden, UT 84403801-387-4500M-F 5PM-9PM Sat-Sun 10AM-4PM


emihealth.com15

INTERMOUNTAIN INSTACARESM & KIDSCARESM FACILITIES

1

3

45

6

87

9

1214

15 16 1719

2021 22

24 2526

2728

1 North Cache Valley InstaCare

2 Logan InstaCare / KidsCare

3 Box Elder InstaCare

4 McKay Dee InstaCare / KidsCare

5 South Ogden InstaCare

6 Herefordshire InstaCare

7 Syracuse InstaCare

8 Layton InstaCare / KidsCare

9 Kaysville Creekside InstaCare

10 Bountiful InstaCare / KidsCare

11 Salt Lake Clinic InstaCare

12 North Temple Urgent Care

13 Holladay InstaCare

14 Park City Bonanza InstaCare

15 Tooele InstaCare

16 Taylorsville InstaCare / KidsCare

17 Memorial InstaCare / Memorial KidsCare

18 Cottonwood InstaCare

19 West Jordan InstaCare / KidsCare

20 Southridge InstaCare / Southridge KidsCare

21 Sandy InstaCare

22 Mountain View KidsCare

23 Draper InstaCare

24 Saratoga InstaCare

25 American Fork InstaCare

26 Highland InstaCare

27 North Orem InstaCare

28 Provo InstaCare

29 Springville InstaCare

30 Payson InstaCare

31 Cedar City InstaCare

32 Sunset InstaCare

33 River Road InstaCare

34 Hurricane Valley InstaCare

BOX ELDER

TOOELE

CACHE

WEBER

DAVIS

SUMMIT

UTAH

SALTLAKE

29

30

11 13

18

23

31

3233

34

IRON

WASHINGTON

2

10

V1.010716

16

Administered by Educators Health Plans Life, Accident, and Health, Inc.

EMI Health Customer Service 801-270-2880 or 1-800-662-5851

Self Funded Employee Medical Benefit Plan

UT 0 1500 90%

2019 Contract Year Participating Non-Participating

Provider Option Provider Option

GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit

Out-of-Pocket Maximum (Per Person/Family Per Year). Please note * $1,500 / $3,000 $3,000 / $6,000

Medical Deductible (Per Person/Family Per Year). Please note ♦ None $500 / $1,000

Non-Preauthorization Patient Penalty Not Applicable 50% Reduction in Benefits

Non-Preauthorization Provider Sanction 50% Reduction in Payment Not Applicable

PRESCRIPTION DRUG BENEFITS (If brand is purchased when generic is

available, member pays the copay plus the difference between the generic

and the brand price)

Participating Pharmacy (30 day supply)

Non-Participating Pharmacy

Mail Order (90 day supply)

Specialty Pharmacy (90 day supply)

All fills must be purchased through Express Scripts Specialty Pharmacy.

Specialty Pharmacy SaveOnSP Program 1-800-683-1074

http://emihealth.com/pdf/saveon.pdf

PREVENTIVE SERVICES

Routine Physical Exam (1 visit per Year) Covered 100% Not Covered

Routine Gynecological Exam (1 visit per Year) Covered 100% Not Covered

Family History Exam (1 visit per Year) Covered 100% Not Covered

Routine Pap Smear & Mammogram (1 per Year) Covered 100% Not Covered

Routine Well-Baby Exams Covered 100% Not Covered

Covered Immunizations Covered 100% Not Covered

Routine Vision Exam (1 visit per Year) Covered 100% Not Covered

Routine Hearing Exam (1 visit per Year) Covered 100% Not Covered

PHYSICIAN & PROFESSIONAL SERVICES

Physician Office Visits (primary care) $25 ♦40%

Physician Office Visits (secondary care) $35 ♦40%

Physician Office Visits (after hours) $35 ♦40%

Physician Visits (Inpatient) 10% ♦40%

Physician Visits (Outpatient) 10% ♦40%

Major Diagnostic Test, CT Scan, MRI, NMR (office) 10% ♦40%

Minor Diagnostic Test, Radiology, Lab (office) Covered 100% ♦40%

Minor Diagnostic Test, Radiology, Lab (Inpatient) 10% ♦40%

Minor Diagnostic Test, Radiology, Lab (Outpatient) Covered 100% ♦40%

Injections (office) Covered 100% ♦40%

Surgery (office) Covered 100% ♦40%

Surgery (Inpatient) 10% ♦40%

Surgery (Outpatient) 10% ♦40%

Anesthesiology (office) Covered 100% ♦40%

Anesthesiology (Inpatient) 10% ♦40%

Anesthesiology (Outpatient) 10% ♦40%

Routine Prenatal & Delivery (Dependent maternity included) 10% ♦40%

Home Health and Hospice Care (in lieu of Hospital) (for supplies, see Medical

Supplies and Equipment)10% ♦40%

Rehabilitation Therapy (Outpatient physical, speech, occupational, cardiac, or

pulmonary - 20 visits per Year)$25 ♦40%

Chiropractic Therapy (20 visits per Year) $25 ♦40%

Must enroll to receive:

$0 Copay

YOU PAY

YOU PAY

Not Covered

Generic - $25

Preferred - $63

Non-Preferred - 50%

25% ($250 Max)

YOU PAY

Generic - $10

Non-Preferred - 50%

Preferred - $25

YOU PAY

All services are subject to the EMI Health Maximum Allowable Charges. When using a Non-participating Provider, the Covered Person is

responsible for all fees in excess of the Maximum Allowable Charge.

Care Plus

Calendar Year

26

17

UT 0 1500 90%



Care Plus

Allergy Testing 10% ♦40%

Allergy Treatment/Serum 10% ♦40%

HOSPITAL/FACILITY BENEFITS

(Physician & Professional Services are not included in this section.)

Medical/Surgical/Maternity/Intensive Care (semi-private room) 10% ♦40%

Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) 10% ♦40%

Skilled Nursing Facility (30 days per Year) (Admission must be within 5 days of

discharge from Hospital Confinement)10% ♦40%

Medical/Surgical Care (Outpatient) 10% ♦40%

Emergency Room (ER) $150 $150

Major Diagnostic Test, CT Scan, MRI, NMR (Outpatient) 10% ♦40%

Minor Diagnostic Test, X-ray, Lab (Inpatient) 10% ♦40%

Minor Diagnostic Test, X-ray, Lab (Outpatient) Covered 100% ♦40%

Newborn 10% 40%

InstaCare/Urgent Care Clinic $35 ♦40%

Eligible Preventive Services Covered 100% Not Covered

REHABILITATION THERAPY BENEFIT

Inpatient – physical, speech, occupational, cardiac, or pulmonary (40 days per

person per Year)10% ♦40%

ACCIDENT AND LIFE THREATENING CONDITION

Medical/Surgical – Physician/Facility/ER Covered as any other condition

Ambulance Land/Air (Accident & Life-threatening) 20%

Orthodontic Injury Treatment *50%

Dental Injury Treatment 20%

TRANSPLANT BENEFIT

Heart, Liver, Pancreas, Bone Marrow, Cornea, Lung, Kidney Covered as any other condition Not Covered

MEDICAL SUPPLIES & EQUIPMENT

Diabetic Testing Supplies (90 day supply) $63 ♦40%

Medical Supplies 10% ♦40%

Medical Supplies (office) Covered 100% ♦40%

Durable Medical Equipment/Prosthetics/Orthotic Devices 10% ♦40%

Orthotic Supplies (foot inserts & arch supports) 10% ♦40%

Growth Hormone 10% ♦40%

MENTAL HEALTH & DRUG/ALCOHOL TREATMENT

Inpatient Services (non-residential) 10% ♦40%

Residential Treatment (30 days per Year) 10% ♦40%

Outpatient Services 10% ♦40%

Physician Office Visits

Psychologist / LCSW / APRN / Psychiatrist$25 ♦40%

ADDITIONAL BENEFITS YOU PAY

Adoption Indemnity Benefit

TMJ Syndrome diagnosis & non-surgical treatment *50% Not Covered

Orthognathic/Mandibular Osteotomy *50% Not Covered

Total Parenteral Nutrition (TPN) *50% Not Covered

Initial assessment and diagnosis of Primary Infertility *50% Not Covered

Reduction Mammoplasty *50% Not Covered

Services designated ♦ are subject to first dollar Medical Deductible

PROVIDER NETWORK

Utah

Outside of Utah Cigna PPO

PLEASE NOTE: This is a summary only and does not guarantee benefits. All benefits are subject to the terms, limitations, and exclusions set forth in the Plan

document and in the Summary Plan Description (SPD)/handbook of the Plan. Any discrepancies between this summary, the SPD/handbook, and the Plan document

are resolved in favor of the Plan document. For more information, including Preauthorization, refer to the SPD/ handbook or the Plan document, or contact EMI

Health Customer Service Department.

The Plan pays a maximum of $4,000 towards adoption expenses.

EMI Health Care Plus

Services designated *, premiums, balance-billed charges, charges for services this Plan doesn’t cover, amounts in excess of benefit limits, and penalties for

failure to obtain Preauthorization, do not accumulate toward your Out-of-pocket Maximum.

YOU PAY

YOU PAY

Covered as a Participating Benefit to

the Maximum Allowable Charge

YOU PAY

YOU PAY

YOU PAY

YOU PAY

18




UT 500 3000 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit


Medical Deductible (Per Person/Family Per Year). Please note ♦ $500 / $1,000 $1,000 / $2,000













PREVENTIVE SERVICES













Physician Visits (Inpatient) ♦20% ♦50%

Physician Visits (Outpatient) ♦20% ♦50%

Major Diagnostic Test, CT Scan, MRI, NMR (office) ♦20% ♦50%


Minor Diagnostic Test, Radiology, Lab (Inpatient) ♦20% ♦50%




Surgery (Inpatient) ♦20% ♦50%

Surgery (Outpatient) ♦20% ♦50%


Anesthesiology (Inpatient) ♦20% ♦50%

Anesthesiology (Outpatient) ♦20% ♦50%

Routine Prenatal & Delivery (Dependent maternity included) ♦20% ♦50%


Supplies and Equipment)♦20% ♦50%





$0 Copay

YOU PAY

YOU PAY

Not Covered

Generic - $25

Preferred - $88

Non-Preferred - 50%

25% ($250 Max)

YOU PAY

Generic - $10

Non-Preferred - 50%

Preferred - $35

YOU PAY



Care Plus

Calendar Year

26

19

UT 500 3000 80%



Care Plus





Medical/Surgical/Maternity/Intensive Care (semi-private room) ♦20% ♦50%

Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) ♦20% ♦50%


discharge from Hospital Confinement)♦20% ♦50%

Medical/Surgical Care (Outpatient) ♦20% ♦50%


Major Diagnostic Test, CT Scan, MRI, NMR (Outpatient) ♦20% ♦50%

Minor Diagnostic Test, X-ray, Lab (Inpatient) ♦20% ♦50%


Newborn 20% 50%





person per Year)♦20% ♦50%



Ambulance Land/Air (Accident & Life-threatening) ♦20%

Orthodontic Injury Treatment ♦*50%

Dental Injury Treatment ♦20%

TRANSPLANT BENEFIT




Medical Supplies ♦20% ♦50%


Durable Medical Equipment/Prosthetics/Orthotic Devices ♦20% ♦50%

Orthotic Supplies (foot inserts & arch supports) ♦20% ♦50%

Growth Hormone ♦20% ♦50%


Inpatient Services (non-residential) ♦20% ♦50%

Residential Treatment (30 days per Year) ♦20% ♦50%

Outpatient Services ♦20% ♦50%





TMJ Syndrome diagnosis & non-surgical treatment ♦*50% Not Covered

Orthognathic/Mandibular Osteotomy ♦*50% Not Covered

Total Parenteral Nutrition (TPN) ♦*50% Not Covered

Initial assessment and diagnosis of Primary Infertility ♦*50% Not Covered

Reduction Mammoplasty ♦*50% Not Covered


PROVIDER NETWORK

Utah










YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

YOU PAY

20




UT 1000 3500 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit


Medical Deductible (Per Person/Family Per Year). Please note ♦ $1,000 / $2,000 $2,000 / $4,000













PREVENTIVE SERVICES

































$0 Copay

YOU PAY

YOU PAY

Not Covered

Generic - $25

Preferred - $88

Non-Preferred - 50%

25% ($250 Max)

YOU PAY

Generic - $10

Non-Preferred - 50%

Preferred - $35

YOU PAY



Care Plus

Calendar Year

26

21

UT 1000 3500 80%



Care Plus














Newborn 20% 50%











TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah










YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

YOU PAY

22




UT 1500 4500 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit















PREVENTIVE SERVICES

































$0 Copay

YOU PAY

YOU PAY

Not Covered

Generic - $25

Preferred - $88

Non-Preferred - 50%

25% ($250 Max)

YOU PAY

Generic - $10

Non-Preferred - 50%

Preferred - $35

YOU PAY



Care Plus

Calendar Year

26

23

UT 1500 4500 80%



Care Plus














Newborn 20% 50%











TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah










YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

YOU PAY

24




UT 2000 5000 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit















PREVENTIVE SERVICES

































$0 Copay

YOU PAY

YOU PAY

Not Covered

Generic - $25

Preferred - $88

Non-Preferred - 50%

25% ($250 Max)

YOU PAY

Generic - $10

Non-Preferred - 50%

Preferred - $35

YOU PAY



Care Plus

Calendar Year

26

25

UT 2000 5000 80%



Care Plus














Newborn 20% 50%











TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah










YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

YOU PAY

26




UT 2500 6000 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit















PREVENTIVE SERVICES

































$0 Copay

YOU PAY

YOU PAY

Not Covered

Generic - $25

Preferred - $88

Non-Preferred - 50%

25% ($250 Max)

YOU PAY

Generic - $10

Non-Preferred - 50%

Preferred - $35

YOU PAY



Care Plus

Calendar Year

26

27

UT 2500 6000 80%



Care Plus














Newborn 20% 50%











TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah










YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

YOU PAY

28




UT 3000 6500 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit















PREVENTIVE SERVICES

































$0 Copay

YOU PAY

YOU PAY

Not Covered

Generic - $25

Preferred - $88

Non-Preferred - 50%

25% ($250 Max)

YOU PAY

Generic - $10

Non-Preferred - 50%

Preferred - $35

YOU PAY



Care Plus

Calendar Year

26

29

UT 3000 6500 80%



Care Plus














Newborn 20% 50%











TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah










YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

YOU PAY

30




UT 5000 7350 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit















PREVENTIVE SERVICES

































$0 Copay

YOU PAY

YOU PAY

Not Covered

Generic - $38

Preferred - 25%

Non-Preferred - 50%

25% ($250 Max)

YOU PAY

Generic - $15

Non-Preferred - 50%

Preferred - 25%

YOU PAY



Care Plus

Calendar Year

26

31

UT 5000 7350 80%



Care Plus














Newborn 20% 50%











TRANSPLANT BENEFIT



Diabetic Testing Supplies (90 day supply) 25% ♦50%




















PROVIDER NETWORK

Utah










YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

YOU PAY

32




UT 1500 3000 QHDHP 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit

Out-of-Pocket Maximum (Per Single/Family Per Year) $3,000 / $6,000 $6,000 / $12,000

Medical Deductible (Per Single/Family Per Year). Please note ♦ $1,500 / $3,000 $3,000 / $6,000











PREVENTIVE SERVICES










Physician Office Visits (primary care) ♦20% ♦40%

Physician Office Visits (secondary care) ♦20% ♦40%

Physician Office Visits (after hours) ♦20% ♦40%




Minor Diagnostic Test, Radiology, Lab (office) ♦20% ♦40%


Minor Diagnostic Test, Radiology, Lab (Outpatient) ♦20% ♦40%

Injections (office) ♦20% ♦40%

Surgery (office) ♦20% ♦40%



Anesthesiology (office) ♦20% ♦40%







pulmonary - 20 visits per Year)♦20% ♦40%

Chiropractic Therapy (20 visits per Year) ♦20% ♦40%

Allergy Testing ♦20% ♦40%

Calendar Year

26

YOU PAY



Care Plus

YOU PAY

♦Generic - $10

♦Non-Preferred - 50%

♦Preferred - 25%

Not Covered

♦Generic - $25

♦Preferred - 25%


♦25% ($250 Max)

YOU PAY

YOU PAY

33

UT 1500 3000 QHDHP 80%



Care Plus

Allergy Treatment/Serum ♦20% ♦40%








Emergency Room (ER) ♦20% ♦20%



Minor Diagnostic Test, X-ray, Lab (Outpatient) ♦20% ♦40%

Newborn ♦20% ♦40%

InstaCare/Urgent Care Clinic ♦20% ♦40%








Orthodontic Injury Treatment ♦20%


TRANSPLANT BENEFIT



Diabetic Testing Supplies (90 day supply) ♦25% ♦40%


Medical Supplies (office) ♦20% ♦40%









Psychologist / LCSW / APRN / Psychiatrist♦20% ♦40%



TMJ Syndrome diagnosis & non-surgical treatment ♦20% Not Covered

Orthognathic/Mandibular Osteotomy ♦20% Not Covered

Total Parenteral Nutrition (TPN) ♦20% Not Covered

Initial assessment and diagnosis of Primary Infertility ♦20% Not Covered

Reduction Mammoplasty ♦20% Not Covered


PROVIDER NETWORK

Utah

Outside of Utah

YOU PAY

YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

Cigna PPO



are resolved in favor of the Plan document. For more information, including Preauthorization, refer to the SPD/ handbook or the Plan document, or contact EMI Health

Customer Service Department.


Single/Family note: The Single Deductible and Out-of-Pocket Maximum amounts apply only to those Covered Persons with single coverage. Covered

Persons with family (two-party or more) coverage, must meet the Family Deductible and Out-of-Pocket Maximum amounts, either individually or

accumulatively as a family.




34




UT 1500 5000 QHDHP 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit













PREVENTIVE SERVICES

































Calendar Year

26

YOU PAY



Care Plus

YOU PAY

♦Generic - $10


♦Preferred - 25%

Not Covered

♦Generic - $25

♦Preferred - 25%


♦25% ($250 Max)

YOU PAY

YOU PAY

35

UT 1500 5000 QHDHP 80%



Care Plus
























TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah

Outside of Utah

YOU PAY

YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

Cigna PPO












36




UT 2000 4000 QHDHP 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit













PREVENTIVE SERVICES

































Calendar Year

26

YOU PAY



Care Plus

YOU PAY

♦Generic - $10


♦Preferred - 25%

Not Covered

♦Generic - $25

♦Preferred - 25%


♦25% ($250 Max)

YOU PAY

YOU PAY

37

UT 2000 4000 QHDHP 80%



Care Plus
























TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah

Outside of Utah

YOU PAY

YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

Cigna PPO












38




UT 3000 5000 QHDHP 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit

Out-of-Pocket Maximum (Per Person/Family Per Year) $5,000 / $10,000 $10,000 / $20,000












PREVENTIVE SERVICES

































Calendar Year

26

YOU PAY



Care Plus

YOU PAY

♦Generic - $10


♦Preferred - 25%

Not Covered

♦Generic - $25

♦Preferred - 25%


♦25% ($250 Max)

YOU PAY

YOU PAY

39

UT 3000 5000 QHDHP 80%



Care Plus
























TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah

Outside of Utah

YOU PAY

YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

Cigna PPO









40




UT 3500 4500 QHDHP 90%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit













PREVENTIVE SERVICES

































Calendar Year

26

YOU PAY



Care Plus

YOU PAY

♦Generic - $10


♦Preferred - 25%

Not Covered

♦Generic - $25

♦Preferred - 25%


♦25% ($250 Max)

YOU PAY

YOU PAY

41

UT 3500 4500 QHDHP 90%



Care Plus
























TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah

Outside of Utah

YOU PAY

YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

Cigna PPO









42




UT 4000 4000 QHDHP 100%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit













PREVENTIVE SERVICES










Physician Office Visits (primary care) ♦Covered 100% ♦40%

Physician Office Visits (secondary care) ♦Covered 100% ♦40%

Physician Office Visits (after hours) ♦Covered 100% ♦40%

Physician Visits (Inpatient) ♦Covered 100% ♦40%

Physician Visits (Outpatient) ♦Covered 100% ♦40%

Major Diagnostic Test, CT Scan, MRI, NMR (office) ♦Covered 100% ♦40%

Minor Diagnostic Test, Radiology, Lab (office) ♦Covered 100% ♦40%

Minor Diagnostic Test, Radiology, Lab (Inpatient) ♦Covered 100% ♦40%

Minor Diagnostic Test, Radiology, Lab (Outpatient) ♦Covered 100% ♦40%

Injections (office) ♦Covered 100% ♦40%

Surgery (office) ♦Covered 100% ♦40%

Surgery (Inpatient) ♦Covered 100% ♦40%

Surgery (Outpatient) ♦Covered 100% ♦40%

Anesthesiology (office) ♦Covered 100% ♦40%

Anesthesiology (Inpatient) ♦Covered 100% ♦40%

Anesthesiology (Outpatient) ♦Covered 100% ♦40%

Routine Prenatal & Delivery (Dependent maternity included) ♦Covered 100% ♦40%


Supplies and Equipment)♦Covered 100% ♦40%


pulmonary - 20 visits per Year)♦Covered 100% ♦40%

Chiropractic Therapy (20 visits per Year) ♦Covered 100% ♦40%

Allergy Testing ♦Covered 100% ♦40%

Calendar Year

26

YOU PAY



Care Plus

YOU PAY

♦Generic - Covered 100%

♦Non-Preferred - Covered 100%

♦Preferred - Covered 100%

Not Covered

♦Generic - Covered 100%

♦Preferred - Covered 100%

♦Non-Preferred - Covered 100%

♦Covered 100%

YOU PAY

YOU PAY

43

UT 4000 4000 QHDHP 100%



Care Plus

Allergy Treatment/Serum ♦Covered 100% ♦40%



Medical/Surgical/Maternity/Intensive Care (semi-private room) ♦Covered 100% ♦40%

Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) ♦Covered 100% ♦40%


discharge from Hospital Confinement)♦Covered 100% ♦40%

Medical/Surgical Care (Outpatient) ♦Covered 100% ♦40%

Emergency Room (ER) ♦Covered 100% ♦Covered 100%

Major Diagnostic Test, CT Scan, MRI, NMR (Outpatient) ♦Covered 100% ♦40%

Minor Diagnostic Test, X-ray, Lab (Inpatient) ♦Covered 100% ♦40%

Minor Diagnostic Test, X-ray, Lab (Outpatient) ♦Covered 100% ♦40%

Newborn ♦Covered 100% ♦40%

InstaCare/Urgent Care Clinic ♦Covered 100% ♦40%




person per Year)♦Covered 100% ♦40%



Ambulance Land/Air (Accident & Life-threatening) ♦Covered 100%

Orthodontic Injury Treatment ♦Covered 100%

Dental Injury Treatment ♦Covered 100%

TRANSPLANT BENEFIT



Diabetic Testing Supplies (90 day supply) ♦Covered 100% ♦40%

Medical Supplies ♦Covered 100% ♦40%

Medical Supplies (office) ♦Covered 100% ♦40%

Durable Medical Equipment/Prosthetics/Orthotic Devices ♦Covered 100% ♦40%

Orthotic Supplies (foot inserts & arch supports) ♦Covered 100% ♦40%

Growth Hormone ♦Covered 100% ♦40%


Inpatient Services (non-residential) ♦Covered 100% ♦40%

Residential Treatment (30 days per Year) ♦Covered 100% ♦40%

Outpatient Services ♦Covered 100% ♦40%


Psychologist / LCSW / APRN / Psychiatrist♦Covered 100% ♦40%



TMJ Syndrome diagnosis & non-surgical treatment ♦Covered 100% Not Covered

Orthognathic/Mandibular Osteotomy ♦Covered 100% Not Covered

Total Parenteral Nutrition (TPN) ♦Covered 100% Not Covered

Initial assessment and diagnosis of Primary Infertility ♦Covered 100% Not Covered

Reduction Mammoplasty ♦Covered 100% Not Covered


PROVIDER NETWORK

Utah

Outside of Utah

YOU PAY

YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

Cigna PPO









44




UT 5000 6500 QHDHP 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit













PREVENTIVE SERVICES

































Calendar Year

26

YOU PAY



Care Plus

YOU PAY

♦Generic - $10


♦Preferred - 25%

Not Covered

♦Generic - $25

♦Preferred - 25%


♦25% ($250 Max)

YOU PAY

YOU PAY

45

UT 5000 6500 QHDHP 80%



Care Plus
























TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah

Outside of Utah

YOU PAY

YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

Cigna PPO









46




UT 6000 6650 QHDHP 80%



GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit













PREVENTIVE SERVICES

































Calendar Year

26

YOU PAY



Care Plus

YOU PAY

♦Generic - $10


♦Preferred - 25%

Not Covered

♦Generic - $25

♦Preferred - 25%


♦25% ($250 Max)

YOU PAY

YOU PAY

47

UT 6000 6650 QHDHP 80%



Care Plus
























TRANSPLANT BENEFIT























PROVIDER NETWORK

Utah

Outside of Utah

YOU PAY

YOU PAY

YOU PAY



YOU PAY

YOU PAY

YOU PAY

Cigna PPO









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May-09Jun-09Jul-09

Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10Feb-10Mar-10

Loss Ratio

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50

90001 Sample GroupDental Experience Report

Incurred from Apr 2009 to Sep 2010

Paid through Oct 2010

Incurred Received Total 12 mo. Claims 12 mo. PremiumMonth Claims Premium 12 mo. LR EE EE + 1 Family Subscribers Dependents Members PEPM PEPMApr-09 $172,351.89 $199,305.60 89.8% 831 848 1,630 3,309 6,682 9,991 53.45 59.53May-09 $151,441.98 $201,828.33 88.9% 838 847 1,640 3,325 6,704 10,029 53.19 59.83Jun-09 $213,433.53 $201,085.46 88.6% 830 840 1,647 3,317 6,710 10,027 53.27 60.11Jul-09 $250,121.63 $201,774.30 88.7% 833 839 1,644 3,316 6,702 10,018 53.56 60.41Jul 09 $250,121.63 $201,774.30 88.7% 833 839 1,644 3,316 6,702 10,018 53.56 60.41

Aug-09 $207,079.50 $201,368.00 88.9% 834 835 1,650 3,319 6,719 10,038 53.96 60.71Sep-09 $173,488.70 $218,027.80 89.0% 844 842 1,686 3,372 6,880 10,252 53.97 60.60Oct-09 $178,444.92 $218,013.50 89.2% 850 844 1,681 3,375 6,870 10,245 54.40 61.01Nov-09 $142,043.82 $217,810.16 88.7% 844 842 1,681 3,367 6,873 10,240 54.47 61.40Dec-09 $177,192.46 $219,112.87 87.6% 846 847 1,696 3,389 6,929 10,318 54.16 61.80Jan-10 $183,932.01 $219,074.52 87.3% 850 847 1,695 3,392 6,920 10,312 54.34 62.22Feb-10 $172,276.24 $218,664.70 87.7% 844 845 1,694 3,383 6,925 10,308 54.91 62.61Mar-10 $208,196.88 $219,447.68 88.0% 847 836 1,702 3,385 6,939 10,324 55.41 63.00Apr-10 $147,732.19 $217,035.40 86.4% 839 828 1,690 3,357 6,901 10,258 54.73 63.36May-10 $135,506.56 $218,781.14 85.2% 841 833 1,685 3,359 6,900 10,259 54.29 63.73Jun-10 $209,251.96 $219,479.13 84.4% 833 833 1,686 3,352 6,914 10,266 54.14 64.13Jul-10 $222,757.60 $217,989.64 82.8% 819 838 1,686 3,343 6,920 10,263 53.42 64.49Jul 10 $222,757.60 $217,989.64 82.8% 819 838 1,686 3,343 6,920 10,263 53.42 64.49

Aug-10 $211,912.10 $217,666.01 82.5% 817 840 1,688 3,345 6,929 10,274 53.51 64.85Sep-10 $154,477.06 $220,749.13 81.7% 798 834 1,700 3,332 7,040 10,372 53.09 64.98Total $3,311,641.04 $3,847,213.37 Incurred claims amounts include IBNR for the loss ratio.

88.0%

90.0%

92.0%

76.0%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

Los

s R

atio

Network Report

% Out-of-Network % Total %33.6% $114,007.85 28.2% $1,080,999.96 33.0%29 9% $97 593 26 24 1% $957 361 21 29 2%

Type In-Network$966,992.11$859 767 95

Type 1 - PreventiveType 2 - Basic

76.0%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

Los

s R

atio

29.9% $97,593.26 24.1% $957,361.21 29.2%31.0% $165,635.80 40.9% $1,057,558.14 32.3%5.4% $27,369.90 6.8% $182,754.24 5.6%

87.7% $404,606.81 12.3% $3,278,673.55 100.0%$140.15 $121.37

$46.98 $40.62

Category Report

% of ClaimsPaid

19.3%$

# ofProcedures

34,455 Claims Paid

$631,511.26Diagnostic

$859,767.95

Total Claims Paid

Type 3 - MajorType 4 - Orthodontics

Type 2 - Basic

Avg Claim $Avg Procedure $

Category

$891,922.34$155,384.34

$2,874,066.74$119.13

$39.86

76.0%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

Los

s R

atio

14.3%21.1%17.8%8.1%2.4%0.5%0.0%0.9%1.7%7.3%5.6%1.2%

100 0%$3 2 8 6 3

2,601 2,080

1,520 Prosthodontics, removable 138

80 21,492

Prosthodontics, fixed

$468,914.68$693,291.92$583,539.36

11,991 3,517

Preventive

Implant Services

Periodontics1,502

Oral Surgery

Restorative - BasicRestorative - Major

Orthodontics

Endodontics

Maxillofaxial Prosthetics

Adjunctive General Services

$263,980.82$78,245.06$15,342.40

$71.00$28,217.22$54,282.18

$240,354.66$182,706.74

$38,216.25

275

20,938

214 2

76.0%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

Los

s R

atio

100.0%

Standard report for groups with over 50 subscribers

$3,278,673.55Total 80,725

76.0%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

Los

s R

atio

51

TM

EMI.M

KTG

.UT-

CHKL

ST.0

917.

1111

Checklist for securing your medical rates with EMI Health

emihealth.com

Securing your medical rates with EMI Health is easy.l Group name, address(es), SIC codel Member level census of all eligible employees including first and last name, birth date, gender, zip code, and coverage tierl Current plan designl Current and renewal ratesl Individual health questionnaires for groups from 10 - 25 currently enrolled employees l Individual health questionnaires are preferred for groups between 26-50, but not required.l Group risk evaluation form for groups of 26 or more currently enrolled employeesl Group and Plan Information Forml Claims experience for groups over 100 enrolled or self-fundedl Individual health questionnaires for any size group if no current coverage is offered

52

Required for all Groups

Group Name: Desired Effective Date:

Address: City / ZIP/ County:

Phone: Nature of Business:

Years in Business: Fed Tax ID:

Total # of Full - time Employees: % Participation:

Number of EE's residing Out of Area: % Turn Over:

Location(s) with zip-code: Number of COBRA Enrollees:

Current Health Carrier: How long?

Employer Contribution (Medical): Employee Dependent

Employer Contribution(Dental): Employee Dependent

Waiting Period:

Plan 1 Employee OnlyEmployee +

Spouse

Employee +

Child(ren)Family

Renewal

Current

Prior


Spouse

Employee +

Child(ren)Family

Renewal

Current

Prior


Spouse

Employee +

Child(ren)Family

Renewal

Current

Prior

Health & Wellness Initiatives Date of Last

Health Fair:

Years In Place:


Spouse

Employee +

Child(ren)Family

Renewal

Current

Prior


Spouse

Employee +

Child(ren)Family

Renewal

Current

Prior

Client Notes: (Please share any additional information that you would like the underwriter to know:

Additional Information

Medical Rates and Plan Information

Previous Carriers (5 years):

Dental Rates and Plan Information

Description

(Carrier, effective date, deductible, coinsurance, HDHP, etc.)

Description


Description

Description

Group and Plan Information

Group Information

Description


53

Required for all Groups

Group Risk Evaluation

Group Name

Yes No

Yes No

Yes No

Yes No

Yes No

For any question above answered "Yes", please complete the following:

Health status

Employee Signature Title Date

Agent Signature Agency Date

Alcohol/Substance abuse Hodgkin's Disease / Lymphoma Muscular Dystrophy

Questionnaire

1. Have covered employees or dependents ever had, consulted a health care professional, or received counseling or treatment for:(Circle all that apply and explain below)?

AIDS / HIV Heart Disease Multiple Sclerosis

Blood Disorders Hypertension Nervous System / MuscularCancer Infertility Organ DisorderCerebral Palsy Kidney / Urinary Rheumatoid ArthritisColitis Leukemia SarcoidosisCrohn's Disease Liver Sexually Transmitted DiseasesDiabetes Lung Strokes

Additional Details

Digestive System Lupus TransplantsEmphysema Mental / Emotional Tumors

2. Are any employees or dependents currently pregnant? If so, list the expected delivery date, and any complications including the anticipation of multiple births or C-section?3. Have any employees or dependents been hospitalized (inpatient or outpatient) or had any surgical operations during the past 5 years?4. Have any employees been absent from work or confined to the home or incapacitated for more than 2 consecutive weeks due to illness or injury during the past 5 years?5. Have any employees or dependents been advised to undergo medical treatment, surgical operations, diagnostic testing or hospitalization in the next 6 months?6. Are any employees or dependents receiving disability benefits of any type including Social Security Income, Worker's Compensation and Medicare?

Question #Employee or dependent

Age & GenderList condition, disorder, disease, problem

and treatmentDates of care: first / last due

date if pregnantCost of care: actual or

expected

I certify to the best of my knowledge that the above information is true, complete and accurate and acknowledge that any coverage issued by the Plan will be issued in reliance thereon.

Signature

54

For Groups with less than 50 Employees

Group Name: YES NO YES NO

Employee's Name: Age: Enroll: If no, other coverage?

Spouse's Name: Age: Enroll: If no, other coverage?

Number of Dependent Children: Age(s): Enroll: If no, other coverage?

Employee's Height: ______ ft. ______in. Spouse's Height: ______ ft. ______in.

Employee's Weight: ______now; ______ one year ago Spouse's Weight: ______now; ______ one year ago

Are you or your dependents afflicted or diagnosed with a major disease or illness? (If yes, explain below) YES NO

Are you or your dependents anticipating any medical or surgical treatment in the next year? (If yes, explain below) YES NO

Do you or your dependents current take any prescription medication? (If yes, explain below) YES NO

Have you or your dependents used any type of tobacco product within the past 5 years? (If yes, explain below) YES NOHealth Information (Please use the back of the form if needed)

Expense

Prescription Medication Information (Please use the back of the form if needed)Expense

Employee Signature Date

I certify that the information stated above is true and correct and acknowledge that any coverage issued by the Plan will be issued in reliance thereon.

Individual Health Questionnaire

Employee Information

Health Information

Please include: Blood Disorders, Cancer (include type), Congenital Disorders, Cystic Fibrosis, Diabetes, Pregnancy (anticipated complications), Liver Disease, Heart Disease, Transplants (include type), Multiple Sclerosis, or other major illnesses.

Individual Name Date (First / Last) Diagnosis Prognosis

Individual Name Date (First / Last) Name and Dosage of Medication Reason for Medication

Signature

55

emihealth.com

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MURRAY, UTAH 84107

LOCAL:

TOLL FREE:

801.262.7475

800.662.5851

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