Select Med Employer SelectHealth by wuzhenguang

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									STEVE BAKER

DAVIS SCHOOL DISTRICT

45 E STATE ST

FARMINGTON, UT 84025




Dear STEVE:




Thank you for choosing SelectHealth. We appreciate your business. The following January 1, 2010
contract has been e-mailed to you in .pdf format.

                                              Select Med

Please sign and return this page to signify that you agree to and wish to be bound by the terms
specified in the above mentioned contract. We look forward to the upcoming year of providing your
employees and their families with convenient, affordable, quality health care. If you have any questions
or concerns, please don't hesitate to call me at (801) 442-7712.

                                                                                             Brent Hogan

                                                                                             SelectHealth

Execution of this document by both parties is required to validate the contractual relationship specified
in the contract listed above. Please sign and return this document.




 Date:                                                  Date:            8/2/2010



              Employer                                              SelectHealth


 By:                                                    By:



 Printed                                                Printed     Patricia R. Richards
 Name:                                                  Name:
 Title                                                  Title:      President / Chief Executive Officer
 Address:                                               Address:    4646 West Lake Park Boulevard

                                                                    Salt Lake City, Utah 84120
group health
 insurance contract
        Table of ConTenTs


        seCTion 1—inTroduCTion .................................................................................................................................... 1

        seCTion 2—Premium .............................................................................................................................................. 1

        seCTion 3—Coverage ........................................................................................................................................... 1

        seCTion 4—eligibiliTy and enrollmenT .......................................................................................................2

        seCTion 5—resPonsibiliTies of The ParTies ................................................................................................2

        seCTion 6—TerminaTion ......................................................................................................................................3

        seCTion 7—general ..............................................................................................................................................3

        seCTion 8—definiTions ....................................................................................................................................... 4




                                                                                                                                                                                 Table of ConTenTs




LE-CONTRACT 01/01/10                                                                                                                                                         i
seCTion 1—inTroduCTion                                        We are an insurance company that insures the Employer
                                                              Plan and the federal court will determine the level of
1.1 Contract.
                                                              discretion that it will accord our determinations.
 This Group Health Insurance Contract (Contract) is
 made between SelectHealth, Inc. (“we” or “us”) and           If the Contract is not part of an employee benefit
 the employer indicated in the Group Application              plan subject to ERISA, this Provision 1.5 does not
 (“you”). In exchange for your payment of Premium, we         apply and is not considered part of the Contract.
 provide defined healthcare Benefits to Members. Any
 payment of Premium will constitute your agreement           seCTion 2—Premium
 to the terms of the Contract, regardless of whether
                                                             2.1 employer responsibility.
 you have actually signed the Group Application.
                                                              Coverage under the Contract is contingent upon
1.2 selecthealth.                                             your timely payment of Premium. The monthly
 SelectHealth is an HMO licensed by the State of Utah.        Premium amount and due date are set forth in
 We are affiliated with Intermountain Healthcare,             the Group Application. Your obligation to make
 but are a separate company. The Contract does                Premium payments is not contingent upon your
 not involve Intermountain Healthcare or any                  ability to collect any Subscriber contributions.
 other affiliated Intermountain companies, or their
                                                             2.2 Premium rates.
 officers or employees. Such companies are not
                                                              The Premium rates specified in the Group Application
 responsible for our obligations or actions.
                                                              will remain the same until the end of the Contract term.
1.3 agency.                                                   However, should federal or state laws or regulations
 You do not have the authority to act as our agent.           mandate that we modify Benefits under the Contract,
 We are not your agent for any purpose. You agree             then we may reasonably modify the Premium rates.
 to act in a timely and diligent manner as the
                                                             2.3 grace Period.
 agent of your Subscribers for certain purposes,
                                                              There is a 30-day Grace Period for the payment
 such as enrollment and termination procedures,
                                                              of Premium. We will continue to pay Benefits
 providing consent to release information, and
                                                              during the Grace Period, but you will be
 agreeing to the conditions in the Contract.
                                                              responsible for reimbursing us for the amount of
1.4 administration of Contract.                               any Benefits paid if you fail to pay Premium.
 We may adopt reasonable policies, rules, and procedures
                                                             2.4 refund of Premium.
 to help in the administration of the Contract. You agree
                                                              We will refund up to two months of Premiums that
 to abide by all such reasonable policies, rules, and
                                                              you mistakenly pay for individuals not Eligible to be
 procedures that are not inconsistent with the Contract.
                                                              Members. We will not refund more than two months
1.5 erisa and selecthealth's authority.                       of Premium. We are entitled to offset from any refund
 If the Contract is part of an employee benefit plan          the amount of any claims paid for such individuals
 subject to the Employee Retirement Income Security Act       before you notified us that they were not Eligible.
 of 1974 (ERISA), you or your designated employee(s) will
 be the plan administrator and in that capacity hereby       seCTion 3—Coverage
 delegate to us the following discretionary authority:       3.1 Certificate of Coverage.
                                                              We will provide you with a copy of each applicable
 Benefits under the Contract will be paid only if we
                                                              Certificate of Coverage, which describes
 decide in our discretion that the Claimant is entitled to
                                                              the Benefits offered under the Contract in
 them. We also have discretion to determine Eligibility
                                                              exchange for your payment of Premium.
                                                                                                                          seCTion 1—inTroduCTion
 for Benefits and to interpret the terms and conditions
 of the benefit plan. Our determinations under this          3.2 administrative Processes.
 reservation of discretion do not prohibit or prevent a
                                                              We establish reasonable administrative processes
 Claimant from seeking judicial review in federal court.
                                                              for claims adjudication, Member Services, Healthcare
 The reservation of discretion made under this provision      Management, and other functions. Members
 only establishes the scope of review that a federal          and Participating Providers and Facilities are
 court will apply when a Claimant seeks judicial review       required to cooperate with these processes when
 of our determination of Eligibility for Benefits, the        obtaining and providing Covered Services.
 payment of Benefits, or interpretation of the terms
                                                             3.3 no vested rights.
 and conditions applicable to the health benefit plan.
                                                              No Member has a vested right to any Covered Services.
                                                              Changes to the Contract may be made without notifying,


LE-CONTRACT 01/01/10                                                                                                  1
                                        consulting with, or obtaining the consent of Members.         4.4 enrolling a dependent
                                        The rights and interest of Members at any particular time     because of a Court order.
                                        depend on the Contract terms in effect at that time.           We will enroll Dependents as the result of a valid court
                                                                                                       order. Compliance with, and administration of, court
                                       seCTion 4—eligibiliTy and enrollmenT                            orders, including Qualified Medical Child Support Orders
                                       4.1 eligibility.                                                (QMCSO's) is your responsibility. When you direct us to
                                                                                                       enroll an individual on the basis of a QMCSO, we reserve
                                        In consultation with us, you decide which categories
                                                                                                       the right to review and confirm that the order is qualified.
                                        of employees, retirees and Dependents are Eligible
                                        to become Members and establish related Eligibility           4.5 Cobra or utah mini-Cobra
                                        requirements. The Eligibility criteria are specified in the   Coverage (Continuation Coverage).
                                        Certificate of Coverage and the Group Application. You
                                                                                                       Continuation Coverage is your obligation. We are not
                                        may not change, extend, expand, or waive the Eligibility
                                                                                                       the administrator of Continuation Coverage procedures
                                        criteria without first obtaining the advance, written
                                                                                                       and requirements. We agree to assist you in providing
                                        approval of an officer of SelectHealth. Only individuals
                                                                                                       Continuation Coverage in certain circumstances.
                                        who continuously satisfy the Eligibility criteria of the
                                                                                                       It is your responsibility to timely: notify persons
                                        Contract may be enrolled and continue as Members. You,
                                                                                                       entitled to Continuation Coverage, notify us of such
                                        your Subscribers, and their Dependents are responsible
                                                                                                       individuals, and collect and submit to us all applicable
                                        for obtaining and submitting to us evidence of Eligibility.
                                                                                                       Premiums. If the Contract is terminated, Continuation
                                       4.2 Changes in member information or eligibility.               Coverage with us will terminate. You are responsible
                                                                                                       for obtaining substitute coverage. You may engage
                                        You must notify us within 31 days whenever there is a
                                                                                                       the services of a third party contractor to assist with
                                        change in a Member's situation that may affect Eligibility
                                                                                                       the administration of Continuation Coverage.
                                        or enrollment. This includes the following events:
                                                                                                      4.5.1 minimum extent.
                                         a. Adoption of a child, birth of a child, or gaining legal
                                            guardianship of a child;                                   Continuation Coverage will only be provided for
                                                                                                       the minimum time and only to the minimum extent
                                         b. Child loses Dependent status;
                                                                                                       required by applicable state and federal law. We
                                         c. Death;                                                     will not provide Continuation Coverage if you or the
                                                                                                       Member fails to strictly comply with all applicable
                                         d. Divorce;
                                                                                                       notice and other requirements and deadlines.
                                         e. Marriage;
                                                                                                      4.5.2 documentation.
                                         f. Involuntary loss of other coverage;                        You are required to provide sufficient documentation
                                         g. Member called to active military duty;                     of a Member's eligibility for Continuation Coverage. We
                                                                                                       determine whether the documentation is sufficient.
                                         h. You receive a Qualified Medical Child Support Order
                                            (QMCSO);                                                  4.6 right to decline enrollment.
                                         i. Reduction in employment hours;                             We may decline to enroll individuals who do not
seCTion 4—eligibiliTy and enrollmenT




                                                                                                       satisfy the Eligibility criteria of the Contract.
                                         j. Subscriber takes, returns from, or does not return
                                            from a leave of absence;
                                                                                                      seCTion 5—resPonsibiliTies
                                         k. Termination of employment.                                of The ParTies
                                        If you fail to notify us within 31 days of a Member's         5.1 Compliance.
                                        termination from employment or other event that                Each party is responsible for its own compliance with
                                        results in the loss of a Member's Eligibility, you agree       applicable laws, rules, and regulations. For you, this
                                        to promptly pay us any un-recovered amounts paid as            includes the reporting and disclosure requirements of
                                        Benefits for such Member before we were notified.              ERISA, all applicable requirements under Titles I and II
                                                                                                       of HIPAA, and any other state and federal requirements
                                       4.3 enrollment.
                                                                                                       that apply to the Employer Plan. You must notify us when
                                        In order for an Eligible individual to receive Benefits,       you receive Medicare secondary payer information.
                                        you must enroll the individual, we must accept
                                        the individual as a Member, and you must pay the              5.2 indemnification.
                                        applicable Premiums. You agree to limit enrollment to          We agree to defend and indemnify you from and against
                                        Subscribers and their Dependents. You are responsible          any claims or other liability based upon our failure to
                                        for submitting the enrollment materials we require.            comply with our obligations under the Contract.




                                        2                                                                                                LE-CONTRACT 01/01/10
 You agree to defend and indemnify us from and against          seCTion 7—general
 any claims or other liability based upon your failure
                                                                7.1 binding effect.
 to comply with your obligations under the Contract.
                                                                 The Contract contains the entire agreement between
5.3 reports.                                                     the parties. In the event you have received a written
 We will help you comply with applicable federal                 proposal, your compliance with the minimum enrollment
 reporting requirements by providing you with                    and underwriting factors set forth in the proposal
 necessary Benefits information in our possession.               is a condition to the effectiveness of the Contract.
                                                                 The Contract is binding upon you, us, Members and
seCTion 6—TerminaTion                                            their heirs, personal representatives and assignees.

6.1 reasons for Termination.                                    7.2 Partial invalidity.
 The Contract, and coverage for all Members under the            If any provision of the Contract is held to
 Contract, can terminate for the reasons listed below.           be unenforceable, it will be deemed to be
                                                                 omitted and the remaining provisions shall
6.1.1 Termination by employer.
                                                                 continue in full force and effect.
 You may terminate the Contract by providing us with
 written notice prior to the date you wish coverage to          7.3 non-assignability.
 end. If you properly notify us, coverage will terminate on      We may designate an affiliated company to
 the last day of the month for which Premium has been            administer some or all of the Plan. Otherwise, the
 paid. We will not accept retroactive termination dates.         parties to the Contract agree that they may not
6.1.2 Termination of employer group by selecthealth.             transfer or assign their rights or obligations without
                                                                 the advance written approval of the other party.
 Your coverage under the Contract may be
 terminated for any of the following reasons:                   7.4 Choice of law.
                                                                 The Contract will be interpreted and enforced according
  a. You fail to pay Premiums in accordance with
     the Contract. Partial payment will be treated as            to the laws and regulations of the State of Utah
     nonpayment unless we, at our sole discretion, indicate      and any applicable federal laws or regulations. If an
     otherwise in writing.                                       inconsistency exists between the Contract and any
                                                                 applicable law, the Contract will be construed to include
  b. You perform an act or practice that constitutes fraud       the minimum requirements of the applicable law.
     or make an intentional misrepresentation of material
     fact under the terms of the coverage.                      7.5 right to audit employer records.
  c. No Members live, reside, or work in the Service Area.       We reserve the right to audit your personnel
                                                                 and/or payroll records to verify the
  d. Your membership in an association, through which the
                                                                 status and Eligibility of Members.
     Contract was made available, ceases.

  e. We cease to offer this particular health benefit           7.6 Term.
     product in accordance with applicable state and             The term of the Contract is specified
     federal law. In such instance, we will give you at least    in the Group Application.
     90 days advance notice.
                                                                7.7 Circumstances beyond Control.
  f. We withdraw from the market in accordance with
     applicable state and federal law. In such instance, we      Neither party will be responsible for a delay in
     will give you at least 180 days advance notice.             performing its obligations under the Contract
  g. You fail to satisfy our minimum participation               due to circumstances reasonably beyond its
     requirements, if applicable.                                control, such as natural disaster, epidemic,
                                                                 riot, war, terrorism, or nuclear release.
6.1.3 employer notice of Termination to subscribers.
                                                                                                                                  seCTion 6—TerminaTion


 It is your responsibility to provide Subscribers a 30-         7.8 Workers' Compensation insurance.
 day written notice of the Contract's termination. We            The Contract does not provide or replace
 will provide you a sample notice upon request.                  workers' compensation coverage for your
                                                                 employees. Employment-related injuries
6.2 liability for services after Termination.
                                                                 are not covered under the Contract.
 We do not cover Services obtained after the
 date of termination, regardless of when a                      7.9 no Waiver.
 condition arose and despite care or treatment                   Failure by either party to insist upon strict compliance
 anticipated or already in progress.                             with any part of the Contract or with any procedure
                                                                 or requirement will not result in a waiver of its right to
                                                                 insist upon strict compliance in any other situation.


LE-CONTRACT 01/01/10                                                                                                          3
                        7.10 notices.                                                   8.9 eligible, eligibility.
                         All required notices shall be sent                              In order to be Eligible, a Subscriber and his/
                         by at least first class mail.                                   her dependent(s) must meet the criteria for
                                                                                         participation specified in the Group Application
                          a. Any notice we are required to send will be sufficient if    and in the Certificate in Section 2—Eligibility.
                             mailed to the address we have on record.

                          b. Any notice we are required to send to a Dependent
                                                                                        8.10 employer Waiting Period.
                             will be sufficient if given to the Subscriber.              The time period that a Subscriber and any Dependent(s)
                                                                                         must wait after becoming Eligible for coverage before
                          c. Any notice you are required to send to us will
                             be sufficient if mailed to the principal office of          the Effective Date. Subject to approval by us, you specify
                             SelectHealth in [Salt Lake City][Murray], Utah.             the length of this period in the Group Application.

                          d. We do not provide COBRA notification services.             8.11 employer Plan.
                                                                                         The group health plan sponsored by you
                        seCTion 8—definiTions
                                                                                         and insured under the Contract.
                         The Contract contains certain defined terms
                                                                                        8.12 endorsement.
                         that are capitalized in the text and described
                         in this section. Words that are not defined have                A document that amends the Contract.
                         their usual meaning in everyday language.
                                                                                        8.13 erisa.
                        8.1 benefit rider.                                               The Employee Retirement Income Security Act (ERISA),
                         Additional coverage purchased by you as noted in the            a federal law governing employee benefit plans.
                         Certificate that modifies Limitations and/or Exclusions.
                                                                                        8.14 exclusion(s).
                        8.2 benefit(s).                                                  Situations and Services that are not covered by
                         The payments and privileges to which                            us under the Plan. Most Exclusions are set forth
                         Members are entitled by the Contract.                           in the Certificate in Section 10—Limitations and
                                                                                         Exclusions, but other provisions throughout the
                        8.3 Certificate of Coverage (Certificate).                       Certificate and the Contract may have the effect
                         The document(s), considered part of the Contract,               of excluding coverage in particular situations.
                         which describe(s) the terms and conditions of the
                                                                                        8.15 facility.
                         health insurance Benefits with us. The Member
                         Payment Summary and any Endorsements are                        An institution that provides certain healthcare
                         attached to, and considered part of, the Certificate.           Services within specific licensure requirements.

                        8.4 Cobra Coverage.                                             8.16 group application.
                         Coverage required by the Consolidated Omnibus                   A form we use both as your application for coverage and
                         Budget Reconciliation Act of 1985 (COBRA).                      to specify group-specific details of coverage. The Group
                                                                                         Application may contain modifications to the language of
                        8.5 Contract.                                                    the Contract. It also demonstrates your acceptance of the
                         The Group Health Insurance Contract, including                  Contract. Other documents, such as Endorsements, may
                         the Group Application, the Certificate of                       be incorporated by reference into the Group Application.
                         Coverage and all other documents expressly
                                                                                        8.17 grace Period.
                         referred to and incorporated by reference.
                                                                                         A specified period of time after a Premium is
                        8.6 Covered services.                                            due during which coverage under the Contract
                         The Services listed in the Certificate in Section               continues and you may pay the Premium.
seCTion 8—definiTions




                         8—Covered Services and applicable Benefit
                                                                                        8.18 limitation(s).
                         Riders and not excluded in the Certificate in
                         Section 10—Limitations and Exclusions.                          Situations and Services in which coverage is limited
                                                                                         by us under the Plan. Most Limitations are set forth
                        8.7 dependent(s).                                                in the Certificate in Section 10—Limitations and
                         A Subscriber's lawful spouse and any child who meets            Exclusions, but other provisions throughout the
                         the Eligibility criteria set forth in the Certificate in        Certificate and the Contract may have the effect
                         Section 2—Eligibility, and the Group Application.               of limiting coverage in particular situations.

                        8.8 effective date.                                             8.19 group health insurance Contract.
                         The date on which coverage for a Member begins.                 See “Contract”


                         4                                                                                                 LE-CONTRACT 01/01/10
8.20 limiting age.
 The maximum age for Dependent coverage,
 as set forth in the Group Application.

8.21 member.
 A Subscriber and any Dependent(s), when properly
 enrolled in the Plan and accepted by us.

8.22 member Payment summary.
 A summary of Benefits by category of service,
 attached to and considered part of the Certificate.

8.23 Plan.
 The specific combination of Covered Services,
 Limitations, Exclusions, and other requirements
 agreed upon between you and us as set forth
 in the Certificate and the Contract.

8.24 Plan sponsor.
 As defined in ERISA. The Plan Sponsor
 is typically the employer.

8.25 Premium(s).
 The amount you periodically pay to us as
 consideration for providing Benefits under the Plan.
 The Premium is specified in the Group Application.

8.26 Provider.
 A vendor of healthcare Services licensed by
 the state where Services are provided and that
 provides Services within the scope of its license.

8.27 Qualified medical Child support order.
 A court order for the medical support
 of a child as defined in ERISA.

8.28 service area.
 As defined in the Certificate(s) of Coverage.

8.29 service(s).
 Services, care, tests, treatments, drugs,
 medications, supplies, or equipment.

8.30 subscriber.
 The individual with an employment or other
 defined relationship to the Plan Sponsor,
 through whom Dependents may be enrolled.
                                                            seCTion 8—definiTions


 Subscribers are also Members.

8.31 utah mini-Cobra.
 Continuation coverage required by Utah law for
 employers with fewer than 20 employees.




LE-CONTRACT 01/01/10                                    5
                                      GROUP APPLICATION



Product                                 Select Med

Employer                                DAVIS SCHOOL DISTRICT

Employer Address                        45 E STATE ST

                                        FARMINGTON, UT 84025



Affiliated Businesses/Subsidiaries Covered by this Application

Employer is hereby applying for, and agreeing to, the terms of the attached Group Health Insurance
Contract with SelectHealth, 4646 West Lake Park Boulevard, Salt Lake City, Utah 84120. SelectHealth is
entering into this Contract in reliance upon the underwriting information supplied by the employer,
which shall be considered to be material representations of fact by employer to SelectHealth.
SelectHealth and employer agree upon the following:




1.      Monthly Premiums.

On or before the first day of each month, employer shall pay the following Premiums to SelectHealth:

 $ 384.80        for each single party enrollment
 $ 831.40        for each Subscriber plus spouse enrollment
 $ 831.40        for each Subscriber plus child enrollment
 $1,120.20       for each Subscriber plus children enrollment
 $1,120.20       for each family enrollment


2.      Eligibility, Prepayment and Enrollment Criteria.

In order to be Eligible, your employees and their Dependents must meet the criteria for participation
and enrollment specified in this Group Application and elsewhere in the Contract. A person may only be
considered an employee if the employer withholds and pays to the government Social Security and
Medicare taxes and income tax withholding on the employee's wages.

2.1     Scheduled hours of work per week.

Your employee must be scheduled to work the requirements below to be Eligible for coverage under
the Plan. During the Employer Waiting Period, the employee must work the minimum required hours
except for paid time off or time the employee does not work due to health status, a medical condition,
the receipt of health care, or disability. SelectHealth may require documentation to verify the number of
hours an employee has worked.




LE-GROUP APP 01/01/10
Employees eligible to participate in the District group insurance plans include:

Employees with an employment start date July 1, 2004, or later, working in a position that is: approved
for 30 or more hours per workweek and approved for at least 168 days each fiscal year; or, approved for
30 or more hours per workweek and approved for a total of at least 1,008 hours each fiscal year.

Employees with an employment start date and insurance eligibility date June 30, 2004, or earlier,
working in a position that is: approved for 20 or more hours per workweek and approved for at least
168 days each fiscal year; or, approved for 20 or more hours per workweek and approved for a total of at
least 704 hours each fiscal year.

Employees with an employment start date June 30, 2004, or earlier, but not eligible for insurance July 1,
2004, working in a position that is: approved for 30 or more hours per workweek and approved for at least
168 days each fiscal year; or, approved for 30 or more hours per workweek and approved for a total of at least
1,008 hours each fiscal year.

If an employee holds more than one position with the district, the authorized hours are combined to
determine insurance eligibility (with the exception of temporary positions).

2.2     Portion of Premium you must contribute.

 93%         for each single party enrollment
 88%         All other tiers

Where the district participates in the cost of insurance premiums, the contribution is prorated based on
authorized hours-per-day for the position.

2.3     Limiting Age.

The Limiting Age is 26 except where the child meets the criteria for disabled children specified in
Section 2-"Eligibility" of the Certificate.

2.4     Retirees.

Retirees are covered. A retired employee is a retiree who has retired under the district incentive
program and elected the Early Retirement Incentive Medical Plan (ERP).

To be eligible for the ERP, employees must have ten years of salary schedule service credit (including
five years current service in the district) and meet the eligibility requirements for and be receiving Utah
State Retirement Systems Benefits within 90 days following retirement. Employees with at least five
but fewer than ten years of salary service credit who meet the above criteria, may also apply for these
benefits on a pro rata basis. Employees and or their dependents who are eligible for Medicare are not
eligible to continue participation in the district's Early Retirement Plan.

Employees who retire under the ERP may continue to be enrolled until they become eligible for
Medicare, or for the ten (10) consecutive years following retirement, whichever occurs first. By electing
participation in this plan, employees and their dependents are electing an alternative to COBRA
participation. Should eligibility in this plan expire before participant reaches Medicare eligibility, the
participant will have Conversion rights.

2.5     Domestic Partners.

Domestic partners are not covered.




LE-GROUP APP 01/01/10
2.6         Leave of Absence.

Eligible employees may be granted up to a 1 year leave of absence by employer or up to the time
allowed for a qualifying leave under the Family Medical Leave Act. Leave time can only be accrued and
used by the employee using the leave time. Leave banks beyond what is required by the FMLA, i.e.
where employees share or purchase leave time from other employees, are not allowed.

During a leave of absence, insurance coverage eligibility is lost at the end of the month in which an
employee:

       i.      Not eligible for family leave, exhausts approved paid leave (or has no available paid leave);
      ii.      Eligible for family leave, exhausts approved paid leave and is beyond the family leave
               period.

2.7         Waiting Period.

The Employer Waiting Period for employees rehired within 12 months of termination who had coverage
at the time of their termination is the date of employment for employees who are re-hired on the first
day of the month. The Employer Waiting Period is the first of the next calender month following the
date of employment for all other re-hired employees. The Employer Waiting Period is the date they are
sworn in for employees designated as Board members. The Employer Waiting Period for employees
designated as Davis Education Association employees is the first of the next calendar month following
90 days of such eligibility. The Employer Waiting Period for all other employees is the first of the next
calendar month following 90 days of such eligibility.

Insurance coverage for employees who have lost and regained eligibility with the district into an
insurance eligible position shall be effective:

       i.      The first day of the month if eligibility occurs on the first day of the month; or
      ii.      The first day of the next calander month if eligibility occurs on the second day of the month
               or later.

When dependent eligibility occurs subsequent to the employee's initial eligibility (e.g. marriage, birth,
adoption) coverage will be effective the date of the event.

An eligible part-time employee who declined coverage when first eligible, but later experiences a
change in approved work hours may apply to enroll if done so within 30 days of the hour change. The
change must be to a total of 35 hours or more per workweek for licensed positions and 37.5 hours or
more per workweek for classified positions. The waiting period for these employees will be the first day
of the month if eligibility occurs on the first day of the month; or the first day of the following month if
eligibility occurs on the second of the month or later.

2.8         Other employees.

Leased employees and independent contractors are not Eligible for coverage by SelectHealth.

2.9         Termination.

Coverage will terminate on the end of the calendar month in which Subscriber and/or Dependents lose
Eligibility. However, if an employee working in a licensed position loses eligibility after the end of the
school year, coverage shall continue through: August 31 for employees working on a traditional
schedule: July 31 for employees working on a year round schedule. If a dependent loses eligibility status
unrelated to the termination of the employee, insurance coverage shall terminate the last day of the
month in which eligibility was lost.




LE-GROUP APP 01/01/10
3.           Duration of Contract.

This Contract is effective on January 1, 2010 to December 31, 2010, for a term of 12 months.

4.           Additional Terms.

4.1          Certificates of Credible Coverage.

SelectHealth will provide the certificates of creditable coverage required under the Health Insurance
Portability and Accountability Act of 1996. SelectHealth will not be responsible for sending certificates
to any employee that may have terminated employment while still in an Employer Waiting Period (i.e.,
before the employee's Effective Date).

4.2          Eligible employees.

Employees eligible to participate in the District group insurance plans include:

        i.      Davis School District Board Member and Employees of the Davis Education Association.
       ii.      A retired employee who has retired under the district incentive program and elected the
                Early Retirement Incentive Medical Plan (ERP).

If an employee and his/her spouse work for the district, both employees shall be eligible for coverage if
they meet other eligibility guidelines. Medical coverage shall be provided under the name of one spouse
only rather than as coordinated coverage for both. Dependent children are eligible to be covered under
only one district-employed parent.

4.3          Eligible Dependents.

        i.      Employee's spouse, if not legally separated from employee.
       ii.      Employee's single children under age 26 for whom the employee has legal responsibility.
      iii.      Employee's children with disabilities (as specifically approved by SelectHealth)

4.4          Long Term Disability (LTD).

Disabled when you are limited from performing the material and substantial duties of your regular
occupation due to sickness or injury; and you have a 20% or more loss in your indexed monthly earnings
due to the same sickness or injury.




LE-GROUP APP 01/01/10
SELECTHEALTH, INC.

DISABILITY WAIVER OF PREPAYMENT FEE

This Endorsement is made between SelectHealth, Inc. and Davis School District. This Endorsement is
effective on January 1, 2010. When signed by the Corporate Officer.

If the Subscriber is approved for a benefit under the Employer sponsored Long-Term Disability Program
which provides income protection for those Subscribers unable to work due to disease or disability, the
Prepayment Fee will be waived, beginning on the fist billing period following the effective date of the
LTD coverage, for a period of up to but not more than 24 months while:

        i.   the Subscriber continues to be Disabled;
       ii.   the Subscriber remains eligible to receive benefits under the Contract in which this
             Endorsement is attached;
      iii.   the Contract is in force; and

Any period of Plan coverage for which an employee's premium is waived under the employer's Long
Term Disability (LTD) plan may run concurrently with and count against an employee's maximum
coverage period under COBRA. After the Prepayment Fee for such Subscriber has been waived for 24
months, the Subscriber will have the option of continuation of coverage as specified under the Contract.
The Maximum Lifetime Benefit for Waiver of Prepayment Fee per Subscriber will be a total of 24
months.

Definition of Disabled.

Disabled means the Subscriber is unable to pursue an occupation for which such Subscriber is
reasonably suited by education, training or experience, due to a physical impairment which:

        i.   was caused by injury or disease;
       ii.   began after the effective date of this Endorsement.
      iii.   has lasted two continuous months; and
      iv.    is not limited or excluded by the Contract

Proof of Continuance of Disability

SelectHealth may require proof that the Subscriber is still disabled at reasonable times during any
period of disability which continues to be covered under this endorsement. In addition, to the
provisions of the Contract and this Endorsement, the benefit under this Endorsement will terminate if
the Subscriber:

        i.   Fails to submit proof of disability when SelectHealth requests it;
       ii.   Fails to submit to a medical exam SelectHealth request; or
      iii.   Is no longer Disabled.

Notice of Recovery or Termination of Employment.

The Employer must give immediate notice to SelectHealth when the Subscriber recovers from a
disability covered under this Endorsement. It will be the responsibility of the Employer to reimburse
SelectHealth for any Prepayment Fees waived, claims paid or expenses incurred for such Subscriber
from the time of recovery until SelectHealth receives written notification of the Subscriber's recovery.

Except as herein specifically provided this Endorsement is subject to all provision, limitations,
exclusions, and agreements of the Contract to which it is attached.

LG-3001 Davis School                                                                        01/01/08
 Date:                 2/26/2010



                       SelectHealth




                       Patricia R. Richards
                       President / Chief Executive Officer




LG-3001 Davis School                                         01/01/08
medical
certificate of coverage
        Table of ConTenTs


        seCTion 1—inTroduCTion .................................................................................................................................... 1

        seCTion 2—eligibiliTy .......................................................................................................................................... 1

        seCTion 3—enrollmenT ......................................................................................................................................3

        seCTion 4—TerminaTion ..................................................................................................................................... 4

        seCTion 5—ConTinuaTion/Conversion Coverage .................................................................................... 5

        seCTion 6—Providers/neTworks ................................................................................................................... 6

        seCTion 7—abouT your benefiTs—mediCal..................................................................................................7

        seCTion 8—Covered serviCes .......................................................................................................................... 8

        seCTion 9—PresCriPTion drug benefiTs ..................................................................................................... 12

        seCTion 10—limiTaTions and exClusions .................................................................................................... 14

        seCTion 11—HealTHCare managemenT.......................................................................................................... 18

        seCTion 12—Claims and aPPeals ................................................................................................................... 19

        seCTion 13—oTHer Provisions affeCTing your benefiTs .................................................................... 25

        seCTion 14—subsCriber resPonsibiliTies .................................................................................................. 26

        seCTion 15—emPloyer resPonsibiliTies...................................................................................................... 26

        seCTion 16—definiTions ................................................................................................................................... 26

        aPPendix a—PresCriPTion drug lisT

        aPPendix b—benefiT riders




                                                                                                                                                                                   Table of ConTenTs




LE-CERT HMO 01/01/10                                                                                                                                                         iii
seCTion 1—inTroduCTion                                        administration of your Benefits. You are subject
                                                              to these administrative practices when receiving
1.1 This Certificate.
                                                              Benefits, but they do not change the express
 This Certificate of Coverage describes the terms and         provisions of this Certificate or the Contract.
 conditions of the health insurance Benefits provided
 under your employer’s Group Health Insurance                1.7 non-assignment.
 Contract with SelectHealth, Inc. Please read it carefully    Benefits are not assignable or transferable. Any
 and keep it for future reference. Technical terms are        attempted assignment or transfer by any Member of the
 capitalized and described in Section 16—Definitions.         right to receive payment from SelectHealth will be invalid
 Your Member Payment Summary, which contains a                unless approved in advance in writing by SelectHealth.
 quick summary of the Benefits by category of service,
 is attached to and considered part of this Certificate.     1.8 notices.
                                                              Any notice required of SelectHealth under the
1.2 selectHealth.                                             Contract will be sufficient if mailed to you at the
 SelectHealth is an HMO licensed by the State of Utah.        address appearing on the records of SelectHealth.
 SelectHealth is affiliated with Intermountain Healthcare,    Notice to your Dependents will be sufficient if given
 but is a separate company. The Contract does not             to you. Any notice to SelectHealth will be sufficient if
 involve Intermountain Healthcare or any other affiliated     mailed to SelectHealth’s principal office. All required
 Intermountain companies, or their officers or employees.     notices must be sent by at least first class mail.
 Such companies are not responsible to you or any other
 Members for SelectHealth’s obligations or actions.          1.9 nondiscrimination.
                                                              SelectHealth will not discriminate against any Member
1.3 managed Care.                                             based on race, sex, religion, national origin, or any
 SelectHealth provides managed healthcare coverage.           other basis forbidden by law. SelectHealth will not
 Such management necessarily limits some choices of           terminate or refuse to enroll any Member because
 Providers and Facilities. The management features            of the health status or the healthcare needs of the
 and procedures are described by this Certificate.            Member or because he or she exercised any right
 The Plan is intended to meet basic healthcare needs,         under SelectHealth’s complaint resolution system.
 but not necessarily to satisfy every healthcare need
 or every desire Members may have for Services.              1.10 Questions.
                                                              If you have questions about your Benefits, call
1.4 your agreement.                                           Member Services at 801-442-5038 (Salt Lake area)
 As a condition to enrollment and to receiving                or 800-538-5038, or visit www.selecthealth.org.
 Benefits from SelectHealth, you (the Subscriber)             SelectHealth offers foreign language assistance.
 and every other Member enrolled through your
 coverage (your Dependents) agrees to:                       1.11 disclaimer.
                                                              SelectHealth employees often respond to
  a. the agency relationships set forth in
                                                              outside inquiries regarding coverage as part
     this Certificate and the Contract;
                                                              of their job responsibilities. These employees
  b. the managed care features that are a part of             do not have the authority to extend or modify
     the Plan in which you are enrolled; and                  the Benefits provided by the Plan.
  c. all of the other terms and conditions of
                                                               a. In the event of a discrepancy between
     this Certificate and the Contract.
                                                                  information given by a SelectHealth employee
1.5 no vested rights.                                             and the written terms of the Contract, the
                                                                  terms of the Contract will control.
 You are only entitled to receive Benefits while the
                                                                                                                              seCTion 1—inTroduCTion

 Contract is in effect and you, and your Dependents            b. Any changes or modifications to Benefits must be
                                                                  provided in writing and signed by the president,
 if applicable, are properly enrolled and recognized
                                                                  vice president, or medical director of SelectHealth.
 by SelectHealth as Members. You do not have any
 permanent or vested interest in any Benefits under            c. Administrative errors will not invalidate Benefits
 the Plan. Benefits may change as the Contract                    otherwise in force or give rise to rights or Benefits
                                                                  not otherwise provided for by the Plan.
 is renewed or modified from year to year. Unless
 otherwise expressly stated in this Certificate,
                                                             seCTion 2—eligibiliTy
 all Benefits end when the Contract ends.
                                                             2.1 general.
1.6 administration.
                                                              Your employer decides, in consultation with SelectHealth,
 SelectHealth establishes reasonable rules, regulations,      which categories of its Employees, retirees, and their
 policies, procedures, and protocols to help it in the        dependents are Eligible for Benefits, and establishes


LE-CERT HMO 01/01/10                                                                                                      1
                         the other Eligibility requirements of the Plan. These         2.3.3 disabled Children.
                         Eligibility requirements are described in this section         Dependent children who meet all of the Eligibility
                         and in the Group Application of the Contract. In               requirements in Subsection 2.3.2 except for age may
                         order to become and remain a Member, you and                   enroll or remain enrolled as Dependents after reaching
                         your Dependents must continuously satisfy these                the Limiting Age as long as they: (1) are unable to
                         requirements. No one, including your employer,                 engage in substantial gainful employment to the degree
                         may change, extend, expand, or waive the Eligibility           they can achieve economic independence due to
                         requirements without first obtaining the advance,              medically determinable physical or mental impairment
                         written approval of an officer of SelectHealth.                which can be expected to last for a continuous period
                                                                                        of not less than 12 months or result in death; (2) are
                        2.2 subscriber eligibility.
                                                                                        chiefly dependent upon you or your lawful spouse
                         You are eligible for Benefits as set forth in the Group
                                                                                        for support and maintenance since they reached
                         Application. During the Employer Waiting Period,
                                                                                        the Limiting Age; and (3) have been continuously
                         you must work the specified minimum required hours
                                                                                        enrolled in some form of healthcare coverage, with
                         except for paid time off and hours you do not work
                                                                                        no break in coverage of more than 63 days since the
                         due to a medical condition, the receipt of healthcare,
                                                                                        date they exceeded the Limiting Age for dependent
                         your health status or disability. SelectHealth may
                                                                                        children. SelectHealth may require you to provide
                         require payroll reports from your employer to verify
                                                                                        proof of incapacity and dependency within 30 days
                         the number of hours you have worked as well as
                                                                                        of the Effective Date or the date the child reaches the
                         documentation from you to verify hours that you did
                                                                                        Limiting Age and annually after the two-year period
                         not work due to paid time off, a medical condition, the
                                                                                        following the child’s attainment of the Limiting Age.
                         receipt of healthcare, your health status or disability.
                                                                                        Despite otherwise qualifying as described above,
                        2.3 dependent eligibility.
                                                                                        a person incarcerated in a prison, jail, or other
                         Unless stated otherwise in the Group                           correctional facility is not a Dependent.
                         Application, your Dependents are:
                                                                                       2.4 Court-ordered dependent Coverage.
                        2.3.1 spouse.
                                                                                        When you or your lawful spouse are required by a court
                         Your lawful spouse under the laws of the state where you       or administrative order to provide health insurance
                         reside. A person of the opposite sex to whom you are           coverage for a child, the child will be enrolled in your
                         not formally married is your lawful spouse only if he or       family coverage according to SelectHealth guidelines and
                         she qualifies as a common law spouse under the laws of         only to the minimum extent required by applicable law.
                         the state where you reside at the time of enrollment. In
                         Utah, you must obtain a court or administrative agency        2.4.1 Qualified medical Child support order (QmCso).
                         order establishing the common law marriage. Eligibility        A QMCSO can be issued by a court of law or by a state or
                         may not be established retroactively. In cases of court        local child welfare agency. In order for the medical child
                         or administrative orders purporting to retroactively           support order to be qualified, the order must specify the
                         either establish or annul/declare void a marriage or           following: (1) your name and last known mailing address
                         divorce, SelectHealth will consider the change effective       (if any) and the name and mailing address of each
                                                                                        alternate recipient covered by the order; (2) a reasonable
                         on the date the court or administrative order was signed
                                                                                        description of the type of coverage to be provided, or
                         by the court or administrative agency, or the date the
                                                                                        the manner in which the coverage will be determined;
                         order is received by SelectHealth, whichever is later.
                                                                                        and (3) the period to which the order applies.
                        2.3.2 Children.
                                                                                       2.4.2 national medical support notice (nmsn).
                         The unmarried children (natural, adopted, and children
                                                                                        An NMSN is a QMCSO issued by a state or local
                         placed for adoption or under legal guardianship through
                                                                                        child welfare agency to withhold from your income
                         testamentary appointment or court order, but not under
                                                                                        any contributions required by the Plan to provide
seCTion 2—eligibiliTy




                         temporary guardianship or guardianship for school
                                                                                        health insurance coverage for an Eligible child.
                         residency purposes) of you or your lawful spouse, who:
                         (1) are under the Limiting Age; and (2) rely on you           2.4.3 eligibility and enrollment.
                         for more than half of their support (as described in           You and the Dependent child must be Eligible for
                         Section 1.152-1 of the Internal Revenue Code).If paternity     coverage, unless specifically required otherwise
                         is in question when determining a Dependent child’s            by applicable law. You and/or the Dependent child
                         Eligibility, the Eligible father must provide the Dependent    will be enrolled without regard to Annual Open
                         child’s birth certificate. If the Eligible father is not       Enrollment restrictions and will be subject to
                         listed on the birth certificate, then he must provide a        applicable Employer Waiting Period requirements.
                         Voluntary Declaration of Paternity that complies with          We will not recognize Dependent Eligibility for a
                         state law. Each of these documents must be notarized.          former spouse as the result of a court order.


                         2                                                                                                 LE-CERT HMO 01/01/10
2.4.4 effective date.                                          first become Eligible, you may not enroll until the
 For a qualified order, the Effective Date                     next Annual Open Enrollment unless you experience
 of coverage will be the later of:                             an event that creates a Special Enrollment Right.

  a. the start date indicated in the order;                   3.4 special enrollment rights.
                                                               SelectHealth provides Special Enrollment
  b. the date any applicable Employer
                                                               Rights in the following circumstances:
     Waiting Period is satisfied; or

  c. The date we receive the order.                           3.4.1 loss of other Coverage.
                                                               If you do not enroll in the Plan for yourself and/
2.4.5 duration of Coverage.
                                                               or your Dependents when initially Eligible, you may
 Court-ordered coverage for the Dependent child will only      enroll at a time other than Annual Open Enrollment
 be provided until the sooner of: (1) the age stated in the    if each of the following conditions is met:
 order; or (2) age 18, except as required by Utah law.
                                                                a. You initially declined to enroll in the Plan due to
seCTion 3—enrollmenT                                               the existence of other health plan coverage;

3.1 general.                                                    b. The loss of the other health plan coverage occurred
                                                                   because of a loss of eligibility (this Special
 You may enroll yourself and your Dependents in
                                                                   Enrollment Right will not apply if the other coverage
 the Plan during the Initial Eligibility Period, under             is lost due to nonpayment of Premiums).There
 a Special Enrollment Right, or, if offered by your                is an exception to this condition for Dependents
 employer, during an Annual Open Enrollment.                       who voluntarily drop their coverage under another
                                                                   large group health plan (more than 51 Subscribers)
 You and your Dependents will not                                  during an open enrollment period for the other
                                                                   large group health plan that does not coincide
 be considered enrolled until:
                                                                   with your Employer’s Annual Open Enrollment. A
                                                                   special enrollment period will be permitted for such
  a. all enrollment information is provided
                                                                   Dependents in order to avoid a gap in coverage; and
     to SelectHealth; and
                                                                c. You and/or your Dependents who lost the other
  b. the Premium has been paid to
                                                                   coverage must enroll in the Plan within 31 days
     SelectHealth by your employer.
                                                                   after the date the other coverage is lost.
3.2 enrollment Process.
                                                               Proof of loss of the other coverage (for example,
 Unless separately agreed to in writing by SelectHealth        a Certificate of Creditable Coverage) must be
 and your employer, you must enroll on a Subscriber            submitted to SelectHealth as soon as reasonably
 Application specified by SelectHealth. You and                possible. Proof of loss of other coverage must be
 your Dependents are responsible for obtaining and             submitted before any Benefits will be paid.
 submitting to SelectHealth evidence of Eligibility
 and all other information required by SelectHealth            Coverage of any Members properly enrolled under
 in the enrollment process. You enroll yourself                this Special Enrollment Right will be effective
 and any Dependents by completing, signing, and                on the date the other coverage was lost.
 submitting a Subscriber Application and any other
                                                              3.4.2 new dependents.
 required enrollment materials to SelectHealth.
                                                               If you are enrolled in the Plan (or are Eligible to be
3.3 effective date of Coverage.                                covered but previously declined to enroll), and gain
 Coverage for you and your Dependents                          a Dependents through marriage, birth, adoption,
 will take effect as follows:                                  placement for adoption or placement under legal
                                                               guardianship with you or your lawful spouse, then you
3.3.1 annual open enrollment.
                                                               may enroll the Dependents (and yourself, if applicable)
                                                                                                                             seCTion 3—enrollmenT


 Coverage elected during your Employer’s                       in the Plan. In the case of birth, adoption or placement
 Annual Open Enrollment will take effect                       for adoption of a child, you may also enroll your Eligible
 on the day the Contract is effective.                         spouse, even if he or she is not newly Eligible as a
                                                               Dependent. However, this Special Enrollment Right is
3.3.2 newly eligible members.
                                                               only available by enrolling within 31 days of the marriage,
 Coverage you elect as a newly Eligible employee will take     birth, adoption, placement for adoption or placement
 effect on the date specified in the Group Application if      under legal guardianship (there is an exception for
 SelectHealth receives a properly completed Subscriber         enrolling a newborn, adopted child, or child placed for
 Application from your employer in a timely manner.            adoption or under legal guardianship if enrolling the
                                                               child does not change the Premium, as explained in
 If you do not enroll in the Plan for yourself and/
 or your Dependents within 31 days of the date you


LE-CERT HMO 01/01/10                                                                                                     3
                         Section 3.5 Enrolling a Newborn, Adopted Child, or Child           a. If enrolling the child requires additional Premium,
                         Placed for Adoption or Under Legal Guardianship).                     you must enroll the child within 31 days of the
                                                                                               child’s birth, adoption, or placement for adoption.
                         Coverage of any Members properly enrolled under this
                                                                                            b. If enrolling the child does not change the Premium,
                         Special Enrollment Right will be effective as indicated:              you must enroll the child within 31 days from
                                                                                               the date SelectHealth mails notification that a
                          a. As of the date of marriage;                                       claim for Services was received for the child.
                          b. As of the date of birth;                                       c. If the child is not enrolled within these time
                                                                                               frames, then you may not enroll the child until
                          c. If the child is less than 31 days old when adopted or
                                                                                               your Employer’s next Annual Open Enrollment.
                             placed for adoption, as of the date of birth; if the child
                             is more than 31 days old when adopted or placed for            d. If you lose Eligibility for coverage before the end of
                             adoption, as of the child’s date of placement; or                 the applicable time frame listed in (a) or (b) above,
                                                                                               you are still allowed to enroll the child within the
                          d. As of the later of:                                               applicable time frame. However, the child will only
                                                                                               be covered from the moment of birth, adoption,
                             i. The effective date of the guardianship court                   placement for adoption or under legal guardianship
                                order or testamentary appointment; or                          until the date that you lost Eligibility for coverage.

                             ii. The date the order is received by SelectHealth.          3.6 leave of absence.
                        3.4.3 divorce/annulment of a                                       If you are granted a temporary leave by your employer,
                        dependent Child’s marriage.                                        you and any Dependents may continue to be enrolled
                                                                                           with SelectHealth for up to the length of time specified
                         You may enroll a Dependent child who newly
                                                                                           in the Group Application, as long as the monthly
                         becomes (re)Eligible as the result of a divorce or an
                                                                                           Premiums for your coverage are paid to SelectHealth
                         annulment of the child’s marriage. You must enroll                by your employer. Military personnel called into
                         any such child within 31 days after the signing by the            active duty will continue to be covered to the extent
                         court of the order granting the divorce/annulment                 required by law. A leave of absence may not be treated
                         or wait until the next Annual Open Enrollment.                    retroactively as a termination of employment.

                         Coverage for any child properly enrolled under this              3.7 family medical leave act.
                         Special Enrollment Right will begin on the effective
                                                                                            If you are on a leave required by the Family
                         date of the divorce/annulment if that date is within six
                                                                                           Medical Leave Act (FMLA), SelectHealth will
                         months of the date of marriage. If the court signs the
                                                                                           administer your coverage as follows:
                         order granting the divorce/annulment more than six
                         months from the date of marriage, coverage for any
                                                                                            a. You and your enrolled Dependents may continue your
                         child properly enrolled will begin on the date the order              coverage with SelectHealth to the minimum extent
                         is received by SelectHealth, without consideration                    required by the FMLA as long as applicable Premiums
                         of any retroactive effect stated in the order.                        continue to be paid to SelectHealth by your employer;

                        3.4.4 Qualification for a subsidy Through                           b. If Premiums are not paid, your coverage will be
                        utah’s Premium Partnership.                                            terminated. Upon your return to work, you and any
                         You and/or your Eligible Dependents who qualify                       previously enrolled Dependents who are still Eligible
                         for a subsidy through the state Medicaid program                      will be prospectively reinstated if the applicable
                                                                                               Premium for you is paid to SelectHealth by your
                         to purchase health insurance may enroll in the Plan
                                                                                               employer within 30 days. SelectHealth will not
                         if application is made within 30 days of receiving
                                                                                               be responsible for any claims incurred by you or
                         written notification of eligibility for the subsidy. If               your Dependents during this break in coverage;
                         you timely enroll, the effective date of coverage is
                         the first of the month following date of enrollment.              Any non-FMLA leave of absence granted
                                                                                           by your employer that could have been
                        3.4.5 loss of medicaid or CHiP Coverage.
                                                                                           classified as FMLA leave will be considered by
seCTion 4—TerminaTion




                         If you and/or your Eligible Dependents lose coverage              SelectHealth as an FMLA leave of absence.
                         under a Medicaid or CHIP plan due to loss of
                         eligibility, you may enroll in the Plan if application           seCTion 4—TerminaTion
                         is made within 60 days. If you enroll within 60
                                                                                          4.1 group Termination.
                         days, the effective date of coverage is the first day
                         after your Medicaid or CHIP coverage ended.                       Coverage under the Plan for you and your Dependents
                                                                                           will terminate when the Contract terminates.
                        3.5 enrolling a newborn, adopted Child, or Child
                        Placed for adoption or under legal guardianship.                  4.1.1 nonrenewal by your employer.

                         You must enroll your newborn, adopted child, child                The Contract is generally issued on an annual
                         placed for adoption or child under legal guardianship             basis. If it is not renewed by your employer, it will
                         according to the following requirements:                          automatically terminate at the end of its term.


                         4                                                                                                     LE-CERT HMO 01/01/10
4.1.2 Termination by employer.                                      they make any fraudulent misrepresentation
                                                                    in connection with insurability.
 Your employer may terminate the Contract, with
 or without cause, by providing SelectHealth with             Please Note: If coverage is terminated as
 written notice of termination not less than 30               described above, the termination will relate
 days before the proposed termination date.                   back to the Effective Date of coverage.

4.1.3 Termination of employer group by selectHealth.           b. After Enrollment. Coverage for you and/
 SelectHealth may terminate the Contract                          or your Dependents may be terminated if
 for any of the following reasons:                                you or they commit fraud or make a material
                                                                  misrepresentation in connection with Benefits.
  a. Nonpayment of applicable Premiums
                                                              If coverage for you or your Dependents is
     by your employer.
                                                              terminated for fraud or material misrepresentation,
  b. Fraud or intentional material misrepresentation to       you or they are allowed to reenroll 12 months
     SelectHealth by your employer in any matter related      after the date of the termination, provided the
     to the Contract or the administration of the Plan.
                                                              Contract is still in force. You will be given notice
  c. Your employer’s coverage under the Contract              of this provision at the time of termination.
     is through an association and your employer
     terminates membership in the association.                The termination from the Plan of a Dependent for cause
                                                              does not necessarily affect your Eligibility or enrollment
  d. Your employer fails to satisfy SelectHealth’s
     minimum group participation and/or                       or the Eligibility or enrollment of your other Dependents.
     employer contribution requirements.
                                                             4.2.3 leaving the service area.
  e. No Members live, reside, or                              Coverage for you and/or your Dependents terminates if
     work in the Service Area.
                                                              you no longer live, work or reside in the Service Area.
  f. SelectHealth elects to discontinue offering a
                                                             4.2.4 annual open enrollment.
     particular health benefit plan. If that happens, you
     will be given at least 90 days advance notice.           You can drop coverage for yourself and any
                                                              Dependents during Annual Open Enrollment.
  g. SelectHealth withdraws from the market
     and discontinues all of its health benefit              4.2.5 retroactive Termination of member.
     plans. If that happens, you will be given
     at least 180 days advance notice.                        If SelectHealth discovers that you or your Dependents
                                                              remained enrolled when no longer Eligible, SelectHealth
4.2 individual Termination.                                   is entitled to retroactively terminate the coverage.
 Your coverage under the Plan may terminate even              SelectHealth is entitled to recover from you and/or your
 though the Contract with your employer remains in force.     Dependents the amount of any Benefits you or they




                                                                                                                            seCTion 5—ConTinuaTion/Conversion Coverage
                                                              receive after losing Eligibility, minus any Premiums paid
4.2.1 loss of eligibility.
                                                              for Services you or they received after losing Eligibility.
 If you and/or your enrolled Dependents lose Eligibility,
 then coverage will terminate at the end of the month        4.3 member receiving Treatment at Termination.
 in which the loss of Eligibility occurred. However, if       All Benefits under the Plan terminate when the
 the Eligibility is lost as the result of a termination       Contract terminates, including coverage for Members
 of employment, your employer may choose on a                 hospitalized or otherwise within a course of care
 uniform and consistent basis to terminate coverage           or treatment. All Services received after the date
 as of the date of termination of employment. If              of termination are the responsibility of the Member
 your Spouse loses Eligibility because you divorce,           and not the responsibility of SelectHealth no
 he or she ceases to be a Member at the end of the            matter when the condition arose and despite care
 month in which the decree of divorce or annulment            or treatment anticipated or already in progress.
 is granted (whether or not the decree finally decides
 all property, support, and custody issues).                 4.4 reinstatement.
                                                              Members terminated from coverage for cause may not be
4.2.2 fraud or misrepresentation.
                                                              reinstated without the written approval of SelectHealth.
  a. During Enrollment.

     i. Coverage for you and/or your Dependents may          seCTion 5—ConTinuaTion/
        be terminated during the two-year period after       Conversion Coverage
        you enroll if you or they make any material
        misrepresentation in connection with insurability.    If your coverage terminates, you or your enrolled
                                                              Dependents may be entitled to continue and/or
     ii. Coverage for you and/or your Dependents              convert coverage. For detailed information about
         may be terminated at any time if you or



LE-CERT HMO 01/01/10                                                                                                   5
                                your rights and obligations under your Employer’s              d. reside in the Service Area;
                                Plan and under federal law, contact your employer.
                                                                                               e. not have lost coverage under the Plan because
                               5.1 Cobra, utah mini-Cobra, or                                     you either failed to pay any required Premium
                                                                                                  contribution or committed fraud or made an
                               alternative to Cobra/utah mini-Cobra
                                                                                                  intentional misrepresentation of material fact; and
                               Coverage (Continuation Coverage).
                                You and/or your Dependents may have the right to               f. submit a written application for
                                                                                                  Conversion Coverage within 60 days of
                                temporarily continue your coverage under the Plan
                                                                                                  losing your coverage under the Plan.
                                when coverage is lost due to certain events. The
                                federal law that governs this right is called COBRA          5.2.3 Conversion Coverage for dependents.
                                (the Consolidated Omnibus Budget Reconciliation Act           You may elect Conversion Coverage on behalf of family
                                of 1986) and generally applies to employers with 20           members who were covered under the Plan on the
                                or more employees. For employers with fewer than 20           date of termination. The only Dependents who may be
                                employees, Utah law provides for mini-COBRA coverage.         added to your Conversion Coverage after it has been
                                Utah law also provides for alternative coverage.              issued are Dependents who become eligible through
                                                                                              birth, adoption, or court or administrative order.
                               5.1.1 employer’s obligation.
                                Continuation Coverage is an employer obligation.              If you are newly eligible for Conversion coverage, but
                                SelectHealth is not the administrator of Continuation         are 65 and choose instead to enroll in Medicare, you
                                Coverage procedures and requirements. SelectHealth            may enroll your Dependents on Conversion Coverage
                                has contractually agreed to assist your employer
                                                                                              for as long as they satisfy the Eligibility requirements.
                                in providing Continuation Coverage in certain
                                circumstances. It is your employer’s responsibility           If you choose to drop Conversion Coverage and
                                to do the following in a timely manner: (1) notify
                                                                                              enroll in Medicare because you turn 65, or in
                                persons entitled to Continuation Coverage, (2) notify
                                                                                              the event of your death, your Dependents may
                                SelectHealth of such individuals, and (3) collect and
                                                                                              remain on Conversion Coverage for as long as
                                submit to SelectHealth all applicable Premiums. If the
                                Contract is terminated, your Continuation Coverage            they satisfy the Eligibility requirements.
                                with SelectHealth will terminate. Your employer is
                                                                                             5.2.4 effective date.
                                responsible for obtaining substitute coverage.
                                                                                              If you properly enroll, Conversion Coverage is effective
                               5.1.2 minimum extent.                                          on the date your coverage under the Plan terminates.
                                Continuation Coverage will only be provided for the
                                                                                             5.2.5 Premium.
                                minimum time and only to the minimum extent required
                                by applicable state and federal law. SelectHealth will not    Your Premium will likely increase but will be
                                provide Continuation Coverage if you, your Dependents,        determined without reference to your health.
                                or your employer fails to strictly comply with all            You must submit your Premium to SelectHealth.
                                applicable notices and other requirements and deadlines.      Failure to make timely Premium payments will
                                                                                              result in termination of Conversion Coverage.
                               5.2 Conversion Coverage.
                                                                                             5.2.6 minimum extent.
                                Under Utah law, you and/or your Dependents may
                                                                                              Conversion Coverage will only be provided for the
                                have the right in certain circumstances to obtain
                                                                                              minimum time and only to the minimum extent required
                                coverage under a separate, individual policy after
                                                                                              by applicable law. SelectHealth will not provide
                                your coverage in the group Contract is terminated.
seCTion 6—Providers/neTworks




                                                                                              Conversion Coverage if you, your Dependents, or
                               5.2.1 notice.                                                  employer fails to strictly comply with all applicable
                                Your employer is required to provide you written              notice, and other requirements and deadlines.
                                notification of your right to Conversion Coverage within
                                                                                             5.2.7 Conversion Coverage may be different.
                                30 days of your losing coverage under the Plan.
                                                                                              You will receive SelectHealth’s standard contract
                               5.2.2 eligibility.                                             for Conversion Coverage in effect at the time your
                                In order to be eligible for Conversion Coverage, you must:    coverage under the Plan terminates, which may
                                                                                              contain otherwise lawful terms, conditions, and
                                 a. have been continuously covered by the Plan                Benefits that are different from those under the Plan.
                                    for a period of six months immediately prior
                                    to the termination of your coverage;
                                                                                             seCTion 6—Providers/neTworks
                                 b. have exhausted Continuation Coverage;
                                                                                             6.1 Providers and facilities.
                                 c. not have acquired other group coverage that               SelectHealth contracts with certain Providers and
                                    covers all conditions that are covered under the Plan;    Facilities (known as Participating Providers and


                                6                                                                                                 LE-CERT HMO 01/01/10
 Participating Facilities) to provide Covered Services        should be made between you and your Provider
 within the Service Area. Not all available Providers         without reference to coverage under the Plan.
 and Facilities and not all categories of Providers and
 Facilities are invited to contract with SelectHealth.
                                                             6.5 Continuity of Care.
                                                              SelectHealth will provide you with 30 days notice
6.2 Providers and facilities not agents/                      of Participating Provider termination if you or your
employees of selectHealth.                                    Dependents are receiving ongoing care from that
 Providers contract independently with SelectHealth           Provider. However, if SelectHealth does not receive
 and are not agents or employees of SelectHealth. They        adequate notice of a Provider termination, SelectHealth
 are entitled and required to exercise independent            will notify you within 30 days of receiving notice that the
 professional medical judgment in providing Covered           Provider is no longer participating with SelectHealth.
 Services. SelectHealth makes a reasonable effort to
 credential Participating Providers and Facilities, but it    If you or your Dependents are under the care of a
 does not guarantee the quality of Services rendered by       Provider when affiliation ceases, SelectHealth will
 Providers and Facilities or the outcomes of medical care     continue to treat the Provider as a Participating Provider
 or health-related Services. Providers and Facilities, not    until the completion of the care (not to exceed 90
 SelectHealth, are solely responsible for their actions,      days), or until you or your Dependent is transferred to
 or failures to act, in providing Services to you.            another Participating Provider, whichever occurs first.
                                                              However, if you or your Dependent is receiving maternity
 Providers and Facilities are not authorized to speak on      care in the second or third trimester, you or they may
 behalf of SelectHealth or to cause SelectHealth to be        continue such care through the first postpartum visit.
 legally bound by what they say. A recommendation,
 order, or referral from a Provider or Facility,              To continue care, the Participating Provider
 including Participating Providers and Facilities,            must not have been terminated by SelectHealth
 does not guarantee coverage by SelectHealth.                 for quality reasons, must remain in the Service
                                                              Area, and agree to all of the following:
 Providers and Facilities do not have authority,
 either intentionally or unintentionally, to modify            a. to accept SelectHealth’s Allowed
                                                                  Amount as payment in full;
 the terms and conditions of the Plan. Benefits are
 determined by the provisions of the Contract.                 b. to follow SelectHealth’s Healthcare
                                                                  Management policies and procedures;
6.3 Payment.
                                                               c. to continue treating you and/
 SelectHealth may pay Providers in one or
                                                                  or your Dependent; and
 more ways, such as discounted fee-for-service,
 capitation (fixed payment per Member per                      d. to share information with SelectHealth
 month), and payment of a year-end withhold.                      regarding the treatment plan.

6.3.1 incentives.                                            seCTion 7—abouT your
 Some payment methods may encourage Providers                benefiTs—mediCal




                                                                                                                            seCTion 7—abouT your benefiTs—mediCal
 to reduce unnecessary healthcare costs and                  7.1 general.
 efficiently utilize healthcare resources. No
                                                              You and your Dependents are entitled to receive
 payment method is ever intended to encourage
                                                              Benefits while you are enrolled with SelectHealth
 a Provider to limit Medically Necessary care.
                                                              and while the Contract is in effect. This section
6.3.2 Payments to members.                                    describes those Benefits in greater detail.

 SelectHealth reserves the right to make                     7.2 member Payment summary.
 payments directly to Members instead of to
                                                              Your Member Payment Summary lists variable
 Nonparticipating Providers and/or Facilities.
                                                              information about your specific Plan. This includes
6.4 Provider/Patient relationship.                            information about Copay, Coinsurance, and/
                                                              or Deductible requirements, Preauthorization
 Providers and Facilities are responsible for establishing
                                                              requirements, visit limits, and expenses that do
 and maintaining appropriate Provider/patient
                                                              not count against the Out-of-Pocket Maximum.
 relationships with you, and SelectHealth does not
 interfere with those relationships. SelectHealth            7.3 identification (id) Cards.
 is only involved in decisions about what Services
                                                              SelectHealth will provide you with ID cards that will
 will be covered and paid for by SelectHealth
                                                              provide certain information about the Plan in which
 under the Plan. Decisions about your Services
                                                              you are enrolled. Providers and Facilities may require
                                                              the presentation of the ID card plus one other reliable


LE-CERT HMO 01/01/10                                                                                                    7
                              form of identification as a condition to providing           7.10 urgent Conditions.
                              Services. The ID card does not guarantee Benefits.            Participating Benefits apply to Services received
                                                                                            for Urgent Conditions rendered by a Participating
                              If you or your enrolled Dependents permit the use of
                                                                                            Provider or Facility. Participating Benefits also apply to
                              your ID card by any other person not covered by the
                                                                                            Services received for Urgent Conditions rendered by
                              card, the card will be confiscated by SelectHealth or
                                                                                            a Nonparticipating Provider or Facility more than 40
                              by a Provider or Facility and all rights of such Member
                                                                                            miles away from any Participating Provider or Facility.
                              under the Plan will be immediately terminated.
                                                                                           7.11 Preauthorization.
                             7.4 medical necessity.
                                                                                            You or your Provider are required to contact SelectHealth
                              To qualify for Benefits, Covered Services must
                                                                                            before you receive certain Services. Depending on
                              be Medically Necessary. Medical Necessity is
                                                                                            the circumstances, your Benefits may be reduced or
                              determined by SelectHealth’s Medical Director or
                                                                                            denied if you do not comply with this requirement.
                              another Physician designated by Selecthealth. A
                                                                                            Refer to Section 11—Healthcare Management and
                              recommendation, order or referral from a Provider
                                                                                            your Member Payment Summary for details.
                              or Facility, including Participating Providers and
                              Facilities, does not guarantee Medical Necessity.
                                                                                           seCTion 8—Covered serviCes
                             7.5 benefit Changes.
                                                                                            You and your Dependents are entitled to receive
                              Your Benefits may change if the Contract changes.             Benefits for Covered Services while you are enrolled
                              Your employer is responsible for providing 30                 with SelectHealth and while the Contract is in effect.
                              days advance written notice of such changes.                  This section describes those Covered Services
                                                                                            (except for pharmacy Covered Services, which are
                             7.6 Calendar-year or Plan-year basis.
                                                                                            separately described in Section 9—Prescription Drug
                              Your Member Payment Summary will indicate if your
                                                                                            Benefits).Certain Services must be Preauthorized;
                              Benefits are calculated on a calendar-Year or plan-
                                                                                            failure to obtain Preauthorization for these Services
                              Year basis. Out-of-Pocket Maximums, Limitations,
                                                                                            may result in a reduction or denial of Benefits.
                              and Deductibles that are calculated on a calendar-
                              Year basis start over each January 1st.Out-of-                Refer to Section 11—Healthcare Management for
                              Pocket Maximums, Limitations, and Deductibles                 a list of Services that must be Preauthorized.
                              that are calculated on a plan-Year basis start over
                              each Year on the renewal date of the Contract.                Benefits are limited; Services must satisfy all of
                                                                                            the requirements of the Contract to be covered by
                             7.7 lifetime maximums.                                         SelectHealth. For additional information affecting
                              Your Member Payment Summary will specify                      Covered Services, refer to your Member Payment
                              any applicable Lifetime Maximums.                             Summary and Section 10—Limitations and Exclusions.

                             7.8 Participating benefits.                                   8.1 facility services.
                                                                                           8.1.1 educational Training.
                              You must use Participating Providers and Facilities to
                              receive Benefits for Covered Services unless otherwise        Only when provided at a Participating
                              noted in the Contract. Participating Providers and            Facility for diabetes or asthma.
                              Facilities have agreed to accept SelectHealth’s Allowed
                                                                                           8.1.2 emergency room (er).
                              Amount and will not bill you for Excess Charges.
                                                                                            If you are admitted directly to the Hospital
                             7.9 emergent Conditions.                                       because of the condition for which emergency
seCTion 8—Covered serviCes




                              Participating Benefits apply to emergency room                room Services were sought, the emergency
                              Services regardless of whether they are received              room Copay, if applicable, will be waived.
                              at a Participating Facility or Nonparticipating
                                                                                           8.1.3 inpatient Hospital.
                              Facility. However, you will have a lower Copay and/
                              or Coinsurance at a Participating Facility.                    a. Semiprivate room accommodations and
                                                                                                other Hospital-related Services ordinarily
                              If you or your Dependent is hospitalized for an                   furnished and billed by the Hospital.
                              emergency in a Nonparticipating Facility:                      b. Private room accommodations in connection
                                                                                                with a medical condition requiring isolation. If
                              a. You or your representative must contact                        you choose a private room when a semiprivate
                                 SelectHealth within two working days, or                       room is available or isolation is not necessary,
                                 as soon as reasonably possible; and                            you are responsible for paying the difference
                                                                                                between the Hospital's semiprivate room rate and
                              b. Once the Emergent Condition has been stabilized, you
                                                                                                the private room rate. However, you will not be
                                 may be asked to transfer to a Participating Facility in
                                                                                                responsible for the additional charge if the Hospital
                                 order to continue receiving Participating Benefits.


                              8                                                                                                LE-CERT HMO 01/01/10
    only provides private room accommodations or                  ii. medical advice, diagnosis, care, or treatment
    if a private room is the only room available.                     was recommended or received for the
                                                                      injury at the time of the accident; and
  c. Intensive care unit.
                                                                  iii. repairs are initiated within one year
  d. Preadmission testing.                                             of the date of the accident.

  e. Short-term inpatient detoxification                       Orthodontia and the replacement/repair of
     provided by a SelectHealth-approved treatment
                                                               dental appliances are not covered, even after an
     Facility for alcohol/drug dependency.
                                                               accident. Repairs for physical damage resulting
  f. Maternity/obstetrical Services.                           from biting or chewing are not covered.

  g. Services in connection with an otherwise                 8.2.4 dietary Products.
     covered inpatient Hospital stay.
                                                               Only in the following limited circumstances:
8.1.4 nutritional Therapy.
                                                                a. For hereditary metabolic disorders when:
 Only when provided at a Participating
 Facility for diabetes, anorexia nervosa,                         i. The Member has an error of amino
 bulimia, polyphagia, or obesity.                                    acid or urea cycle metabolism;

8.1.5 outpatient facility and ambulatory surgical facility.       ii. The product is specifically formulated and
                                                                      used for the treatment of errors of amino
 Outpatient surgical and medical Services.                            acid or urea cycle metabolism; and
8.1.6 skilled nursing facility.                                   iii. The product is used under the direction
 Only when Services cannot be provided                                 of a Physician, and its use remains under
                                                                       the supervision of the Physician.
 adequately through a home health program.
                                                                b. In all other situations when:
8.1.7 urgent Care facility.
8.2 Provider services.                                            i. The formula is used under the direction of
8.2.1 after-Hours visits.                                            a Physician and can only be obtained by
                                                                     prescription and through a pharmacy; or
 Office visits and minor surgery provided after
 the Provider's regular business hours.                           ii. The formula is the Member’s primary
                                                                      source of nutrition and is primarily given
8.2.2 anesthesia.                                                     through a form of feeding tube; or
 If administered in connection with otherwise                     iii. The Member has gastrointestinal dysfunction
 Covered Services and by a Physician certified as an                   (e.g., malabsorption) and the product is
 anesthesiologist or by a Certified Registered Nurse                   specifically designed to be used in the
 Anesthetist (CRNA) under the direct supervision                       management of the condition that prevents his
                                                                       or her ability to maintain adequate weight.
 of a Physician certified as an anesthesiologist.
                                                              8.2.5 genetic Counseling.
8.2.3 dental services.
                                                               Only when provided by a Participating Provider
 Only in three limited circumstances:
                                                               who is a certified genetic counselor.
  a. When rendered to diagnose or treat medical               8.2.6 genetic Testing.
     complications of a dental procedure and administered
     under the direction of a medical Provider whose           Only in the following circumstances and
     primary practice is not dentistry or oral surgery.        according to SelectHealth criteria:


                                                                                                                              seCTion 8—Covered serviCes
  b. When SelectHealth determines the                           a. Prenatal testing when performed as part
     following to be Medically Necessary:                          of an amniocentesis to assess specific
                                                                   chromosomal abnormalities in women at high
    i. maxillary and/or mandibular procedures;                     risk for inheritable conditions that can lead to
                                                                   significant immediate and/or long-term health
    ii. upper/lower jaw augmentation or reduction
                                                                   consequences to the child after birth;
        procedures, including developmental corrections
        or altering of vertical dimension; and                  b. Neonatal testing for specific inheritable
                                                                   metabolic conditions (e.g., PKU);
    iii. orthognathic Services.
                                                                c. When the Member has a more than five-
  c. For repairs of physical damage to sound
                                                                   percent probability of having an inheritable genetic
     natural teeth, crowns, and the supporting
                                                                   condition and has signs or symptoms suggestive
     structures surrounding teeth when:
                                                                   of a specific condition or a strong family history of
    i. such damage is a direct result of an                        the condition (defined as two or more first-degree
       accident independent of disease or                          relatives with the condition) and results of the testing
       bodily infirmity or any other cause;                        will directly affect the patient's treatment; or


LE-CERT HMO 01/01/10                                                                                                    9
                               d. Pre-implantation embryonic genetic testing             8.2.17 sterilization Procedures.
                                  performed to identify an inherited genetic condition   8.3 miscellaneous services.
                                  known to already exist in either parent’s family
                                  which has the potential to cause serious and           8.3.1 adoption indemnity benefit.
                                  impactful medical conditions for the child.             SelectHealth provides an adoption indemnity Benefit
                             8.2.7 Home visits.                                           to the extent required by Utah law. In order to receive
                                                                                          this Benefit, the child must be placed with you for
                              Only if you are physically incapable of
                                                                                          adoption within 90 days of the child's birth and the
                              traveling to the Provider’s office.
                                                                                          adoption must be finalized within one year of the
                             8.2.8 infertility diagnosis and Treatment.                   child’s birth. You must submit a claim for the Benefit
                              Only the following Services:                                within one year from the date of placement.


                              Fulguration of ova ducts, hysteroscopy,                     If you adopt more than one child from the same
                              hysterosalpingogram, certain laboratory                     birth (e.g., twins), only one adoption indemnity
                              tests, and laparoscopy.                                     Benefit applies. If you and/or your spouse are
                                                                                          covered by multiple plans, SelectHealth will cover a
                             8.2.9 major office surgery.                                  prorated share of the adoption indemnity Benefit.
                             8.2.10 mastectomy/reconstructive services.
                                                                                          This Benefit is subject to Coinsurance, Copays, and
                              In accordance with the Women’s Health and Cancer
                                                                                          Deductibles applicable to the maternity Benefit as
                              Rights Act (WHCRA), SelectHealth covers mastectomies
                                                                                          indicated in your Member Payment Summary.
                              and reconstructive surgery after a mastectomy.
                              If you are receiving Benefits in connection with a         8.3.2 allergy Tests,
                              mastectomy, coverage for reconstructive surgery,
                                                                                          Treatment, or Serum. Must be received from a board
                              including modifications or revisions, will be provided
                                                                                          certified allergist, immunologist, or otolaryngologist.
                              according to SelectHealth’s Healthcare Management
                                                                                          Oral food challenge testing only when administered by a
                              criteria and in a manner determined in consultation
                                                                                          Provider who is board certified in allergy/immunology.
                              with you and the attending Physician, for:
                                                                                         8.3.3 ambulance/Transportation services.
                               a. All stages of reconstruction on the breast on
                                                                                          Transport by a licensed service to the nearest Facility
                                  which the mastectomy was performed;
                                                                                          expected to have appropriate Services for the treatment
                               b. Surgery and reconstruction of the other breast          of your condition. Only for Emergent Conditions and
                                  to produce a symmetrical appearance; and                not when you could safely be transported by other
                                                                                          means. Air ambulance transportation only when ground
                               c. Prostheses and treatment of physical
                                                                                          ambulance is either not available or, in the opinion
                                  complications of the mastectomy,
                                                                                          of responding medical professionals, would cause an
                                  including lymphedema.
                                                                                          unreasonable risk of harm because of increased travel
                              Benefits are subject to the same Deductibles, Copays,       time. Transportation services in nonemergency situations
                              and Coinsurance amounts applicable to other medical         must be approved in advance by SelectHealth.
                              and surgical procedures covered by the Plan.               8.3.4 Chemotherapy, radiation Therapy, and dialysis.
                             8.2.11 medical/surgical.                                    8.3.5 Cochlear implants.

                              In an inpatient, outpatient, or                             For prelingual deafness in children or postlingual
                              Ambulatory Surgical Facility.                               deafness in adults in limited circumstances that
                                                                                          satisfy SelectHealth criteria. Must be Preauthorized.
                             8.2.12 Physician office visits including minor surgery.
seCTion 8—Covered serviCes




                                                                                         8.3.6 durable medical equipment (dme).
                              For consultation, diagnosis, and treatment.
                                                                                          Only when used in conjunction with an
                             8.2.13 maternity services.                                   otherwise covered condition and must be:
                              Prenatal care, labor and delivery, and postnatal
                              care, including complications of delivery.                   a. prescribed by a Provider;

                                                                                           b. primarily used for medical purposes and
                             8.2.14 Preventive services.
                                                                                              not for convenience, personal comfort, or
                             8.2.15 second opinions.                                          other nontherapeutic purposes; and
                              Copay/Coinsurance/Deductible waived
                                                                                           c. required for Activities of Daily Living.
                              when requested by SelectHealth.
                                                                                          SelectHealth will not provide payment for rental costs
                             8.2.16 sleep studies.
                                                                                          exceeding the purchase price. For covered rental
                              Only when conducted by a designated sleep-study             DME that is subsequently purchased, cumulative
                              Participating Provider at a Participating Facility.         rental costs are deducted from the purchase price.



                              10                                                                                               LE-CERT HMO 01/01/10
8.3.7 Home Healthcare.                                       All other conditions are considered under
 When you:                                                   the mental health Benefit, if applicable.

                                                            8.3.12 organ Transplants.
  a. have a condition that requires the
     services of a licensed Provider;                         a. Only if:

  b. are home bound for medical reasons;                        i. Preauthorized in advance by SelectHealth; and

  c. are physically unable to obtain necessary                  ii. provided by Participating Providers in a
     medical care on an outpatient basis; and                       Participating Facility unless otherwise approved
                                                                    in writing in advance by SelectHealth.
  d. are under the care of a Physician.
                                                              b. And only the following:
 In order to be considered home bound, you must either:
                                                                i. bone marrow as outlined in SelectHealth criteria
  e. have a medical condition that restricts your ability
     to leave the home without the assistance of another        ii. combined heart/lung
     individual or supportive device or because absences
                                                                iii. combined pancreas/kidney
     from the home are medically contraindicated; or
                                                                iv. cornea
  f. leave the home only to receive medical treatment
     that cannot be provided in your home or other              v. heart
     treatments that require equipment that cannot be
     made available in your home or infrequently and for        vi. kidney (but only to the extent not covered
     short periods of time for nonmedical purposes.                 by any government program)

 You are not considered home bound if you leave the             vii. liver
 home regularly for social activities, drive a car, or do
                                                                viii. pancreas after kidney
 regular grocery or other shopping, work or business.
                                                                ix. single or double lung
8.3.8 Hospice Care.
8.3.9 injectable drugs and specialty medications.            For covered transplants, organ harvesting from donors is
 Up to a 30-day supply, though exceptions can be             covered up to a limit specified in your Member Payment
 made for travel purposes. In general, your Physician        Summary. Services for both the donor and the recipient
 will coordinate the process for obtaining these             are only covered under the recipient’s coverage.
 drugs. You may be required to receive the drug
                                                             Costs of a chartered service if transportation
 or medication in your Physician’s office. Some
                                                             to a transplant site cannot be accomplished
 Injectable Drugs and Specialty Medications may
                                                             within four hours by commercial carrier.
 only be obtained from certain drug distributors. Call
 Member Services to determine if this is the case and       8.3.13 orthotics and other Corrective
 to obtain information on participating drug vendors.       appliances for the foot.
                                                             Not covered unless they are part of a lower foot
8.3.10 miscellaneous medical supplies (mms).
                                                             brace, and they are prescribed as part of a specific
 Only when prescribed by a Physician and not generally       treatment associated with recent, related surgery.
 usable in the absence of an illness or injury.
                                                            8.3.14 osteoporosis screening.
8.3.11 neuropsychological Testing (medical).
                                                             Only central bone density testing (DEXA scan).
 As a medical Benefit, only as follows:
                                                            8.3.15 Private duty nursing.

                                                                                                                            seCTion 8—Covered serviCes
  a. Testing performed as part of the preoperative
                                                             On a short-term, outpatient basis during a
     evaluation for patients undergoing:
                                                             transition of care when ordered by a Physician. Not
    i. seizure surgery                                       available for Respite Care or Custodial Care.

    ii. solid organ transplantation                         8.3.16 rehabilitation Therapy.

    iii. central nervous system malignancy;                  Physical, occupational, and speech rehabilitative
                                                             therapy when required to correct an impairment
  b. Patients being evaluated for
                                                             caused by a covered accident or illness or to restore an
     dementia/Alzheimer’s disease;
                                                             individual’s ability to perform Activities of Daily Living.
  c. Stroke patients undergoing
     formal rehabilitation; and                             8.3.17 robotic-assisted surgery.
                                                             Only as set forth in SelectHealth medical criteria.
  d. Post-traumatic-brain-injury patients.
                                                            8.3.18 Temporomandibular Joint (TmJ).



LE-CERT HMO 01/01/10                                                                                                   11
                                       8.3.19 vision aids.                                           9.3.2 Quantity and day supply.
                                        Only:                                                         Prescriptions are subject to SelectHealth quantity
                                                                                                      and day-supply Limitations. For example, controlled
                                         a. Contacts for Members diagnosed with                       substances such as pain medications and stimulants
                                            keratoconus, congenital cataracts, or when
                                                                                                      are limited to a 30-day supply per prescription.
                                            used as a bandage after eye trauma/injury.

                                         b. Prescribed eyeglasses for Members following              9.3.3 refills.
                                            covered cataract surgery. In such cases, coverage         Refills are allowed after 80 percent of the last
                                            is limited to a lifetime maximum of $100.                 refill has been used. Some exceptions may apply;
                                         c. Monofocal intraocular lenses                              call Member Services for more information.
                                            after cataract surgery.
                                                                                                     9.4 generic drug substitution required.
                                       8.4 Prescription drug services.
                                                                                                      Your Member Payment Summary will indicate if generic
                                        Refer to Section 9—Prescription Drug Benefits for details.    substitution is required. When generic substitution
                                                                                                      is required, the following guidelines apply:
                                       seCTion 9—PresCriPTion drug benefiTs
                                                                                                       a. A Generic Drug will be substituted for a
                                        This section includes important information about                 brand-name drug unless your Provider
                                        how to use your Prescription Drug Benefits. For                   indicates otherwise on the prescription.
                                        additional information, refer to your Member Payment
                                                                                                       b. If you request a brand-name drug instead of a
                                        Summary and Section 10—Limitations and Exclusions.                Generic Drug, then you must pay the difference
                                        Note: this section does not apply to you if your                  between the Allowed Amount for the Generic
                                        Member Payment Summary indicates that your Plan                   Drug and the Allowed Amount for the brand-
                                        does not provide Prescription Drug Benefits.                      name drug, plus your Copay/Coinsurance. The
                                                                                                          difference in cost between the Generic Drug and
                                       9.1 use Participating Pharmacies.                                  brand-name drug will not apply to your pharmacy
                                                                                                          Deductible and Out-of-Pocket Maximum.
                                        To get the most from your Prescription Drug Benefits,
                                        use a Participating Pharmacy and present your                  c. If your Provider prescribes a brand-name drug
                                        ID card when filing a prescription. SelectHealth                  for medical reasons, this penalty will not apply.
                                        contracts with pharmacy chains on a national basis           9.5 maintenance drugs.
                                        and with independent pharmacies in Utah.
                                                                                                      SelectHealth offers a maintenance drug Benefit, allowing
                                        If you use a Nonparticipating Pharmacy, you must              you to obtain a 90-day supply of certain medications.
                                        pay full price for the drug and submit to SelectHealth        This Benefit is available for maintenance drugs you
                                        a Prescription Reimbursement Form with your                   have been using for at least one month and expect to
                                        itemized pharmacy receipt. If the drug is covered,            continue using for the next year. Maintenance drugs
                                        you will be reimbursed the Allowed Amount minus               are identified by the letter (M) on the Prescription Drug
                                        your Copay/Coinsurance and/or Deductible.                     List. You have two options when filling prescriptions
                                                                                                      under the maintenance drug Benefit: Retail90SM, which
                                       9.2 Tiered benefits.                                           is available at certain retail pharmacies, and mail
seCTion 9—PresCriPTion drug benefiTs




                                        There are levels (or tiers) of covered prescriptions          order. Please refer to your Member Payment Summary
                                        listed on your ID card and Member Payment Summary.            or contact Member Services to verify if the 90-day
                                        This tiered Benefit allows you to choose the drugs that       maintenance drug Benefit is available on your Plan.
                                        best meet your medical needs while encouraging you
                                                                                                     9.6 Preauthorization of Prescription drugs.
                                        and your Provider to discuss treatment options and
                                        choose lower-tier drugs as therapeutically appropriate.       There are certain drugs that require Preauthorization
                                                                                                      by your Physician to be covered by SelectHealth.
                                        Drugs on each tier are selected by an expert panel of         Prescription drugs that require Preauthorization
                                        Physicians and pharmacists and may change periodically.       are identified on the Prescription Drug List. The
                                        To determine which tier a drug is assigned to, call           letters (PA) appear next to each drug that requires
                                        Member Services or visit www.selecthealth.org/pharmacy.       Preauthorization. Preauthorization is also required
                                                                                                      if the medication is in excess of the Plan limits
                                       9.3 filling your Prescription.                                 (quantity, duration of use, maximum dose, etc.).
                                       9.3.1 Copay/Coinsurance.
                                        You generally will be charged one Copay/Coinsurance           To obtain Preauthorization for these drugs, please
                                        per covered prescription up to a 30-day supply at a           have your Physician call SelectHealth Pharmacy
                                        retail pharmacy. If your Provider prescribes a dose of        Services at 801-442-4912 (Salt Lake area) or 800-
                                        a medication that is not available, you will be charged       442-3129, or visit www.selecthealth.org.
                                        a Copay for each strength of the medication.


                                        12                                                                                                LE-CERT HMO 01/01/10
 If your Physician prescribes a drug that requires            These medications are not covered
 Preauthorization, you should verify that                     when they are prescribed:
 Preauthorization has been obtained before purchasing
                                                              d. outside the usual standard of care for the
 the medication. You may still buy these drugs if
                                                                 practitioner prescribing the medication;
 they are not Preauthorized, but they will not be
 covered and you will have to pay the full price.             e. in a manner inconsistent with
                                                                 accepted medical practice; or
9.7 step Therapy.
                                                              f. for indications that are Experimental
 Certain drugs require your Provider to first prescribe          and/or Investigational.
 an alternative drug preferred by SelectHealth.
 The alternative drug is generally a more cost-               This exclusion is subject to review by the
 effective therapy that does not compromise clinical          SelectHealth Drug Utilization Panel and certification
 quality. If your Provider feels that the alternative         by a practicing clinician who is familiar with
 drug does not meet your needs, SelectHealth                  the medication and its appropriate use.
 may cover the drug without step therapy if
                                                             9.11 Prescription drug benefit abuse.
 SelectHealth determines it is Medically Necessary.
                                                              SelectHealth may limit the availability and filling
 Prescription drugs that require step therapy are             of any Prescription Drug that is susceptible to
 identified on the Prescription Drug List at the              abuse. A care manager may require you to:
 end of this section. The letters (ST) appear next
                                                              a. obtain prescriptions in limited dosages and supplies;
 to each drug that requires step therapy.
                                                              b. obtain prescriptions only from a specified Physician;
9.8 Prescription drug benefit resources.
 There are several resources you can use to obtain            c. fill your prescriptions at a specified pharmacy;
 information about tiers, Participating Pharmacies,           d. participate in specified treatment for
 Preauthorization requirements, maintenance                      any underlying medical problem (such
 drugs, step therapy, generic substitutions, and                 as a pain management program);
 your Prescription Drug Benefits. You can:
                                                              e. complete a drug treatment program; or
 a. Visit www.selecthealth.org/pharmacy;                      f. adhere to any other specified limitation
                                                                 or program designed to reduce or
 b. Refer to your Provider & Facility Directory;
                                                                 eliminate drug abuse or dependence.
 c. Call Member Services at 801-442-5038 (Salt Lake
    area) or 800-538-5038, or visit www.selecthealth.org.     If you seek to obtain drugs in amounts in excess
                                                              of what is Medically Necessary, such as making
9.9 Coordination of benefits.                                 repeated emergency room/urgent care visits to
 If you have other health insurance that is your primary      obtain drugs, SelectHealth may deny coverage
 coverage, claims must be submitted first to your primary     of any medication susceptible of abuse.
 insurance carrier before being submitted to SelectHealth.
 In some circumstances, your secondary policy may pay         SelectHealth may terminate you from coverage if you




                                                                                                                           seCTion 9—PresCriPTion drug benefiTs
 a portion of your out-of-pocket expense. When you mail       make an intentional misrepresentation of material fact in
 a secondary claim to SelectHealth, you must include a        connection with obtaining or attempting to obtain drugs
 Prescription Reimbursement Form and the pharmacy             or medications, such as by intentionally misrepresenting
 receipt in order for SelectHealth to process your claim.     your condition, other medications, healthcare
 In some circumstances, an Explanation of Benefits            encounters, or other medically relevant information. At
 (EOB) from your primary carrier may also be required.        SelectHealth’s discretion, you may be permitted to retain
                                                              your coverage if you comply with specified conditions.
9.10 inappropriate Prescription Practices.
                                                             9.12 Pharmacy injectable drugs
 In the interest of safety for our Members, SelectHealth
                                                             and specialty medications.
 reserves the right to not cover certain prescription
                                                              While injectable drugs apply to your medical
 medications. These medications include:
                                                              Benefits, some injectable drugs may also be covered
 a. narcotic analgesics;                                      under your Prescription Drug Benefits when filled
                                                              at a pharmacy. For more specific information,
 b. other addictive or potentially
                                                              please contact SelectHealth Member Services.
    addictive medications; and

 c. medications or drugs prescribed in quantities,           9.13 Prescription drug list (Pdl).
    dosages, or usages that are outside the usual             Refer to Appendix A—Prescription Drug List for the PDL.
    standard of care for the medication in question.



LE-CERT HMO 01/01/10                                                                                                  13
                                        9.14 disclaimer.                                              • Passive Cutaneous Transfer Test (P-K Test)
                                                                                                      • Provocative Conjunctival Test
                                         SelectHealth refers to many of the drugs in this
                                                                                                      • Provocative Nasal Test
                                         Certificate by their respective trademarks. SelectHealth
                                                                                                      • Rebuck Skin Window Test
                                         does not own these trademarks. The manufacturer or
                                                                                                      • Rinkel Test
                                         supplier of each drug owns the drug’s trademark. By
                                                                                                      • Subcutaneous Provocative Food and Chemical Test
                                         listing these drugs, SelectHealth does not endorse
                                                                                                      • Sublingual Provocative Food and Chemical Test
                                         or sponsor any drug, manufacturer, or supplier.
                                         Conversely, these manufacturers and suppliers do            The following allergy treatments are not covered:
                                         not endorse or sponsor any SelectHealth service or
                                                                                                      • Allergoids
                                         Plan, nor are they affiliated with SelectHealth.
                                                                                                      • Autogenous urine immunization
                                                                                                      • LEAP therapy
                                        seCTion 10—limiTaTions and exClusions                         • Medical devices (filtering air cleaner, electrostatic
                                                                                                        air cleaner, air conditioners etc.)
                                         Unless otherwise noted in your Member Payment
                                                                                                      • Neutralization therapy
                                         Summary or Appendix B—Benefit Riders, the
                                                                                                      • Photo-inactivated extracts
                                         following Limitations and Exclusions apply.
                                                                                                      • Polymerized extracts
                                        10.1 abortions/Termination of Pregnancy.                      • Oral desensitization/immunotherapy

                                         Abortions are not covered except:                          10.5 anesthesia.

                                         a. When determined by SelectHealth to                       General anesthesia rendered in a
                                            be Medically Necessary to save the life                  Provider’s office is not covered.
                                            or good health of the mother; or
                                                                                                    10.6 attention-deficit/Hyperactivity disorder.
                                         b. Where the pregnancy was caused by a rape
                                                                                                     Cognitive or behavioral therapies for the
                                            or incest if evidence of the rape or incest is
                                            presented either from medical records or through         treatment of these disorders are not covered.
                                            the review of a police report or the filing of
                                            charges that a crime has been committed; or             10.7 bariatric surgery.
                                                                                                     Surgery to facilitate weight loss is not covered. The
                                         c. When there is evidence of grave fetal defects
                                            that are inconsistent with sustaining life.              reversal or revision of such procedures and Services
                                                                                                     required for the treatment of complications from such
                                         Medical complications resulting from an abortion are        procedures are not covered. However, medical or surgical
                                         covered. Treatment of a miscarriage/spontaneous             complications that can be reasonably attributed to such
                                         abortion (occurring from natural causes) is covered.        a surgery will be considered for coverage if they arise ten
                                                                                                     years or more after the surgery. This Exclusion does not
                                        10.2 acupuncture/acupressure.
                                                                                                     apply if your Member Payment Summary indicates that
                                         Acupuncture and acupressure Services are not covered.       your Plan includes the Bariatric Surgery Benefit Rider.

                                        10.3 administrative services/Charges.                       10.8 biofeedback/neurofeedback.
                                         Services obtained for administrative purposes               Biofeedback/neurofeedback is not covered.
seCTion 10—limiTaTions and exClusions




                                         are not covered. Such administrative purposes
                                         include Services obtained for or pursuant to legal         10.9 birthing Centers and Home Childbirth.
                                         proceedings, court orders, employment, continuing           Childbirth in any place other than a Hospital
                                         or obtaining insurance coverage, governmental               is not covered. This includes all Provider and/
                                         licensure, home health recertification, travel, military    or Facility charges related to the delivery.
                                         service, school, or institutional requirements.
                                                                                                    10.10 Certain Cancer Therapies.
                                         Provider and Facility charges for completing                The following cancer therapies are not covered:
                                         insurance forms, duplication services, interest
                                                                                                      • Neutron beam therapy
                                         (except where required by Utah Administration
                                                                                                      • Proton beam therapy
                                         Code R590-192), finance charges, late fees,
                                         shipping and handling, missed appointments, and            10.11 Certain illegal activities.
                                         other administrative charges are not covered.               Services for an illness, condition, accident,
                                                                                                     or injury are not covered if it occurred:
                                        10.4 allergy Tests/Treatments.
                                         The following allergy tests are not covered:                 a. While the Member was a voluntary participant
                                                                                                         in the commission of a felony;
                                          • Cytotoxic Test (Bryan's Test)
                                          • Leukocyte Histamine Release Test                          b. While the Member was a voluntary participant in
                                          • Mediator Release Test (MRT)                                  disorderly conduct, riot, or other breach of the peace;


                                        14                                                                                                 LE-CERT HMO 01/01/10
 c. While the Member was engaged in any                       hormones, massage therapies, aromatherapies,
    conduct involving the illegal use or misuse               yoga, hypnosis, rolfing, and thermography.
    of a firearm or other deadly weapon;
                                                             10.15 Complications.
 d. While the Member was driving or otherwise
   in physical control of a car, truck, motorcycle,           All Services provided or ordered to treat
   scooter, off-road vehicle, boat, or other motor-           complications of a non-Covered Service are not
   driven vehicle if the Member either:                       covered unless stated otherwise in this Certificate.
    i. Had sufficient alcohol in the Member’s body that
                                                             10.16 Custodial Care.
       a subsequent test shows that the Member has
       either a blood or breath alcohol concentration         Custodial Care is not covered.
       of.08 grams or greater at the time of the test; or
                                                             10.17 dental anesthesia.
    ii. Had any illegal drug or other illegal
        substance in the Member’s body to a degree            Services including local, regional, general, and/
        that it affected the Member’s ability to              or intravenous sedation anesthesia, are not
        drive or operate the vehicle safely;                  covered except for at Participating Facilities
                                                              when members meet the following criteria:
 e. While the Member was driving or otherwise in
    physical control of a car, truck, motorcycle, scooter,
                                                              a. Member is developmentally delayed, regardless
    off-road vehicle, boat, or other motor-driven vehicle
                                                                 of the chronological age of the member; or
    either without a valid driver’s permit or license,
    if required under the circumstances or without            b. Member is under five years of age;
    the permission of the owner of the vehicle; or
                                                              c. proposed dental work involves
 f. As a complication of, or as the result                       three or more teeth;
    of, or as follow-up care for, any illness,
    condition, accident, or injury that is not                d. diagnosis is nursing bottle-mouth syndrome
    covered as the result of this exclusion.                     or extreme enamel hypoplasia; and

 The presence of drugs or alcohol may be                      e. proposed procedures are restoration
 determined by tests performed by or for law                     or extraction for rampant decay.
 enforcement, tests performed during diagnosis
                                                              Consideration of coverage will be given to members,
 or treatment, or by other reliable means.
                                                              regardless of age, with congenital cardiac or neurological
10.12 Chiropractic services.                                  conditions who provide documentation that the need
                                                              for dental anesthesia is due to their underlying medical
 Chiropractic Services are not covered. This
                                                              condition and the need to closely monitor this condition.
 Exclusion does not apply if your Member
 Payment Summary indicates that your Plan                    10.18 dry needling.
 includes the Chiropractic Benefit Rider.
                                                              Dry needling procedures are not covered.
10.13 Claims after one year.                                 10.19 duplication of Coverage.
 Claims are denied if submitted more than one year
                                                              The following are not covered:
 after the Services were provided unless notice was




                                                                                                                              seCTion 10—limiTaTions and exClusions
 given or proof of loss was filed as soon as reasonably       a. Services that are covered by, or would have
 possible. Adjustments or corrections to claims can be           been covered if you or your Dependents had
 made only if the supporting information is submitted            enrolled and maintained coverage in:
 within one year after the claim was first processed by          i. Automobile insurance, including no-fault
 SelectHealth unless the additional information relating            type coverage up to the minimum amount
 to the claim was filed as soon as reasonably possible.             required by law. In the event of a claim,
                                                                    you should provide a copy of the Personal
 When SelectHealth is the secondary payer,                          Injury Protection (PIP) documentation from
                                                                    the automobile insurance carrier; or
 Coordination of Benefits will be performed only
 if the supporting information is submitted to                   ii. Workers’ Compensation.
 SelectHealth within one year after the claim was
                                                              b. Services for which you have obtained a
 processed by the primary plan unless the information
                                                                 payment, settlement, judgment, or other recovery
 was provided as soon as reasonably possible.                    for future payment intended as compensation.

10.14 Complementary and                                       c. Services received by a Member incarcerated in
alternative medicine (Cam).                                      a prison, jail, or other correctional facility at the time
                                                                 Services are provided, including care provided outside
 Complementary, alternative and nontraditional Services
                                                                 of a correctional facility to a person who has been
 are not covered. Such Services include acupuncture,             arrested or is under a court order of incarceration.
 homeopathy, homeopathic drugs, certain bioidentical


LE-CERT HMO 01/01/10                                                                                                   15
                                        10.20 experimental and/or investigational services.          be calculated and fairly apportioned to exclude
                                         Experimental and/or Investigational                         any charges related to the non-Covered Service.
                                         Services are not covered.
                                                                                                    10.32 Pain management services.
                                        10.21 eye surgery,                                           The following Services are not covered:
                                         Refractive. Radial keratotomy, LASIK, or                     • Prolotherapy
                                         other eye surgeries performed primarily to                   • Radiofrequency ablation of dorsal root ganglion
                                         correct refractive errors are not covered.                   • Acupuncture
                                                                                                      • IV pamidronate therapy for the treatment
                                        10.22 fitness Training.                                         of reflex sympathetic dystrophy
                                         Fitness training, conditioning, exercise equipment, and    10.33 Pervasive developmental disorder.
                                         membership fees to a spa or health club are not covered.
                                                                                                     Services for Pervasive Developmental
                                        10.23 food supplements.                                      Disorder are not covered.

                                         Except for Dietary Products, as described in               10.34 Prescription drugs/injectable
                                         Section 8—Covered Services, food supplements               drugs and specialty medications.
                                         and substitutes are not covered.
                                                                                                     The following are not covered:
                                        10.24 gene Therapy.                                          a. Appetite suppressants and weight loss medications;
                                         Gene therapy or gene-based therapies are not covered.
                                                                                                     b. Certain off-label drug usage, unless the
                                        10.25 Habilitation Therapy services.                            use has been approved by a SelectHealth
                                                                                                        Medical Director or clinical pharmacist;
                                         Services designed to create or establish function
                                         that was not previously present are not covered.            c. Compound drugs when alternative
                                                                                                        products are available commercially;
                                        10.26 Hearing aids.
                                                                                                     d. Cosmetic health and beauty aids;
                                         Except for cochlear implants, as described in Section
                                         8—Covered Services, the purchase, fitting, or ongoing       e. Drugs purchased from Nonparticipating
                                                                                                        Providers over the Internet;
                                         evaluation of hearing aids, appliances, auditory brain
                                         implants, bone-anchored hearing aids, or any other          f. Flu symptom medications;
                                         procedure or device intended to establish or improve
                                                                                                     g. Drugs and medications purchased through a
                                         hearing or sound recognition is not covered.
                                                                                                        foreign pharmacy. However, please call Member
                                                                                                        Services if you have a special need for medications
                                        10.27 Home Health aides.
                                                                                                        from a foreign pharmacy (for example, for an
                                         Services provided by a home health aide are not covered.       emergency while traveling out of the country);

                                        10.28 immunizations.                                         h. Human growth hormone for the
                                                                                                        treatment of idiopathic short stature;
                                         The following immunizations are not covered:
                                         anthrax, BCG (tuberculosis), cholera,                       i. Infertility medications;
seCTion 10—limiTaTions and exClusions




                                         plague, typhoid, and yellow fever.
                                                                                                     j. Medications not meeting the minimum levels of
                                        10.29 mental Health.                                            evidence based upon Food and Drug Administration
                                                                                                        (FDA) approval and/or DrugDex level IIa strength
                                         Inpatient and outpatient mental health and chemical            of recommendation, and National Comprehensive
                                         dependency Services are not covered. This Exclusion            Cancer Network (NCCN) category 2A, if applicable.
                                         does not apply if your Member Payment Summary
                                                                                                     k. Minerals, fluoride, and vitamins other than
                                         indicates that your Plan includes the Mental                   prenatal or when determined to be Medically
                                         Health/Chemical Dependency Benefit rider.                      Necessary to treat a specifically diagnosed disease;

                                        10.30 methadone Therapy.                                     l. Nicotine and smoking cessation medications,
                                                                                                        except in conjunction with a SelectHealth-
                                         Methadone maintenance/therapy clinics
                                                                                                        sponsored smoking cessation program;
                                         or Services are not covered.
                                                                                                     m. Over-the-counter (OTC) medications, except
                                        10.31 non-Covered service in Conjunction                        when all of the following conditions are met:
                                        with a Covered service.
                                                                                                        i. The OTC medication is listed on the SelectHealth
                                         When a non-Covered Service is performed as part                   formulary as a covered medication;
                                         of the same operation or process as a Covered
                                         Service, only charges relating to the Covered                  ii. The SelectHealth Pharmacy & Therapeutics
                                                                                                            Committee has approved the OTC medication
                                         Service will be considered. Allowed Amounts may
                                                                                                            as a medically appropriate substitution of


                                         16                                                                                            LE-CERT HMO 01/01/10
       a Prescription Drug or medication; and                 10.36 rehabilitation Therapy services.
    iii. The Member has obtained a prescription for the        The following are not covered:
         OTC medication from a licensed Provider and filled
         the prescription at a Participating Pharmacy;         a. Services for functional nervous disorders;

 n. Prescription Drugs used for cosmetic purposes;             b. Vision rehabilitation therapy Services;

 o. Prescriptions written by a licensed dentist,               c. Speech therapy for developmental speech delay.
    except for the prevention of infection or pain
    in conjunction with a dental procedure;
                                                              10.37 related Provider services.
                                                               Services provided to a Member by a Provider
 p. Replacement of lost, stolen, or
                                                               who ordinarily resides in the same household
    damaged drugs and medications;
                                                               as the Member are not covered.
 q. Sexual dysfunction medications. This
    Exclusion does not apply if your Member Payment           10.38 respite Care.
    Summary indicates that your Plan includes                  Respite Care is not covered.
    the Sexual Dysfunction Benefit rider; and
                                                              10.39 sexual dysfunction.
 r. Travel-related medications, including
    preventive medication for the purpose of                   Services related to sexual dysfunction are not
    travel to other countries. See Immunizations               covered. This Exclusion does not apply if your
    In Section 10—Limitations and Exclusions.
                                                               Member Payment Summary indicates that your Plan
10.35 reconstructive, Corrective,                              includes the Sexual Dysfunction Benefit Rider.
and Cosmetic services.
                                                              10.40 specialty services.
 Services provided for the following
                                                               Coverage for specific specialty Services may be
 reasons are not covered:
                                                               restricted to only those Providers who are board
 a. to improve form or appearance;                             certified or have other formal training that is
                                                               considered necessary to perform those Services.
 b. to correct a deformity, whether congenital or
    acquired, without restoring physical function;            10.41 specific services.
 c. to cope with psychological factors such as                 The following Services are not covered:
    poor self-image or difficult social relations;
                                                                • Anodyne infrared device for any indication
 d. as the result of an accident unless the Service             • Auditory brain implantation
    is rendered within 12 months of the cause or onset          • Chronic intermittent insulin IV therapy/
    of the injury, illness, or therapeutic intervention,          metabolic activation therapy
    or a planned, staged series of Services (as                 • Coblation therapy of the soft tissues of
    specifically documented in the Member’s medical               the mouth, nose, throat, or tongue
    record) is initiated within the 12-month period;            • Computer-assisted interpretation of
                                                                  x-rays (except mammograms)
 e. to revise a scar, whether acquired through
                                                                • Extracorporeal shock wave therapy for
    injury or surgery, except when the primary purpose
                                                                  musculoskeletal indications
    is to improve or correct a functional impairment.




                                                                                                                        seCTion 10—limiTaTions and exClusions
                                                                • Cryoablation therapy for plantar
 The following procedures and the treatment for the               fasciitis and Morton’s neuroma
 following conditions are not covered, except as indicated:     • Freestanding/home cervical traction
                                                                • Home anticoagulation or hemoglobin A1C testing
 f. Breast reduction (except according                          • Infrared light coagulation for the
    to SelectHealth criteria);                                    treatment of hemorrhoids
                                                                • Interferential/neuromuscular stimulators
 g. Congenital cleft lip except for treatment
                                                                • Intimal Media Thickness (IMT) testing to
    rendered within 12 months of birth, or a planned,
                                                                  assess risk of coronary disease
    staged series of Services (as specifically
    documented in the Member’s medical record)                  • Lovaas therapy
    is initiated, or when congenital cleft lip surgery          • Magnetic Source Imaging (MSI)
    is performed as part of a cleft palate repair;              • Microprocessor controlled, computerized
                                                                  lower extremity limb prostheses
 h. Port wine stain treatment (except
                                                                • Mole mapping
    according to SelectHealth criteria);
                                                                • Nonsurgical spinal decompression therapy
 i. Sclerotherapy of superficial                                  (e.g., VAX-D or DRS therapy)
    varicose veins (spider veins);                              • Nucleoplasty or other forms of
                                                                  percutaneous disc decompression
                                                                • Pressure Specified Sensory Device
                                                                  (PSSD) for neuropathy testing



LE-CERT HMO 01/01/10                                                                                               17
                                     • Prolotherapy                                              a. All admissions to facilities, including
                                     • Radiofrequency ablation for lateral epicondylitis            rehabilitation, transitional care, skilled
                                     • Radiofrequency ablation of the dorsal root ganglion          nursing, and all routine hospitalizations;
                                     • Secretin infusion therapy for the treatment of autism     b. All nonroutine obstetrics admissions and maternity
                                     • Virtual colonoscopy                                          stays longer than two days for a normal delivery
                                     • Whole body scanning                                          or longer than four days for a cesarean section;

                                   10.42 Telephone/e-mail Consultations.                         c. Home health, hospice, outpatient private Nurse;
                                    Charges for Provider telephone, e-mail, or other             d. Pain management/pain clinic Services;
                                    electronic consultations are not covered.
                                                                                                 e. Selected Prescription Drugs (Refer
                                   10.43 Terrorism or nuclear release.                              to the Prescription Drug List in Appendix
                                                                                                    A—Prescription Drug Benefits);
                                    Services for an illness, injury, or connected disability
                                    are not covered when caused by or arising out of an          f. The following Durable Medical Equipment:
                                    act of international or domestic terrorism, as defined
                                                                                                   i. Insulin pumps and continuous glucose monitors;
                                    by United States Code, Title 18, Section 2331, or from
                                    an accidental, negligent, or intentional release of            ii. Prosthetics (except eye prosthetics);
                                    nuclear material or nuclear byproduct material as
                                                                                                   iii. Negative pressure wound therapy
                                    defined by United States Code, Title 18, Section 831.               electrical pump (wound vac);
                                   10.44 Travel-related expenses.                                  iv. Motorized or customized wheelchairs; and
                                    Costs associated with travel to a local or distant
                                                                                                   v. DME with a purchase price over $5,000.
                                    medical provider, including accommodation
                                    and meal costs, are not covered.                             g. The following Injectable Drugs
                                                                                                    and Specialty Medications*:
                                   10.45 war.                                                  Actimmune
                                                                                               Apokyn
                                    Services for an illness, injury, or connected disability
                                                                                               Araclyst
                                    are not covered when caused by or arising out of           Avastin
                                    a war or an act of war (whether or not declared)           Betaseron
                                                                                               Boniva
                                    or service in the armed services of any country.
                                                                                               Botox
                                                                                               Cimzia
                                   seCTion 11—HealTHCare managemenT                            Erbitux
                                                                                               Euflexxa
                                    SelectHealth works to manage costs while protecting        Fabrazyme
                                                                                               Flolan
                                    the quality of care. The Healthcare Management
                                                                                               Forteo
                                    Program reviews three aspects of medical care:             Genotropin
                                    appropriateness of the care setting, Medical Necessity,    Humatrope
                                                                                               Hyalgan
                                    and appropriateness of Hospital lengths of stay.
                                                                                               Hyaluronate
                                    You benefit from this process because it reduces           Immune Globulin
                                    unnecessary medical expenses, enabling SelectHealth        Increlex
                                                                                               Iplex
                                    to maintain reasonable Premium rates. The Healthcare
                                                                                               Ixempra
seCTion 11—HealTHCare managemenT




                                    Management process takes several forms.                    Kineret
                                                                                               Mecasermin
                                   11.1 Preauthorization.                                      MyoBloc
                                                                                               Norditropin
                                    Preauthorization is prior approval from SelectHealth       Nplate
                                    for certain Services and is considered a Preservice        Nutropin AQ
                                    Claim (refer to Section—12 Claims and Appeals).            Nutropin Depot
                                                                                               Nutropin
                                    Preauthorization is not required when SelectHealth         Orencia
                                    is your secondary plan. However, it is required            Orthovisc
                                    for injectable drugs and inpatient services when           Pegasys
                                                                                               PEG-Intron
                                    Medicare is your primary insurance. Obtaining              Pregnyl
                                    Preauthorization does not guarantee coverage.              Prialt
                                    Your Benefits for the Preauthorized Services are           Profasi
                                                                                               Progesterone
                                    subject to the Eligibility requirements, Limitations,      Protropin
                                    Exclusions and all other provisions of the Plan.           Reclast
                                                                                               Relistor
                                   11.1.1 services requiring Preauthorization.                 Remodulin
                                                                                               Saizen
                                    Preauthorization is required for the                       Soliris
                                    following major Services:                                  Somatrem


                                    18                                                                                               LE-CERT HMO 01/01/10
Somatropin                                                      births), SelectHealth will work with you and your
Somatropin (rDNA origin)                                        family, your Provider, and community resources to
Somavert
Supartz                                                         coordinate a comprehensive plan of care. This integrated
Synagis                                                         approach helps you obtain appropriate care in cost-
Synvisc                                                         effective settings and reduces some of the burden
Tev-Tropin
Torisel                                                         that you and your family might otherwise face.
Tysabri
Vectibix                                                       11.3 benefit exceptions.
Velcade
Ventavis
                                                                On a case-by-case basis, SelectHealth may in its
Xolair                                                          sole discretion extend or add Benefits that are
Zorbtive                                                        not otherwise expressly covered or are limited
 * This list is updated periodically. For the                   by the Plan. In making this decision, SelectHealth
 most current list, visit www.selecthealth.org/                 will consider the medical appropriateness and
 pharmacy or call Member Services.                              cost effectiveness of the proposed exception.

11.1.2 who is responsible for obtaining Preauthorization.       When making such exceptions, SelectHealth reserves
 Participating Providers and Facilities are responsible         the right to specify the Providers, Facilities, and
 for obtaining Preauthorization on your behalf;                 circumstances in which the additional care will be
 however, you should verify that they have obtained             provided and to limit payment for additional Services
 Preauthorization prior to receiving Services.                  to the amount SelectHealth would have paid had the
                                                                Service been provided in accordance with the other
 You are responsible for obtaining Preauthorization when        provisions of the Plan. Benefits paid under this section
 using a Nonparticipating Provider or Facility, or when         are subject to all other Member payment obligations of
 obtaining cochlear implants or organ transplants.              the Plan such as Copays, Coinsurance, and Deductibles.

11.1.3 How to request Preauthorization.                        11.4 second opinions/Physical examinations.
 If you need to request Preauthorization,                       After enrollment, SelectHealth has the right to request
 call Member Services at 801-442-5038                           that you be examined by a mutually agreed upon
 (Salt Lake area) or 800-538-5038.                              Provider concerning a claim, a second opinion request,
                                                                or a request for Preauthorization. SelectHealth will be
 You should call SelectHealth as soon as you
                                                                responsible for paying for any such physical examination.
 know you will be using a Nonparticipating
 Provider or Facility for any of the Services listed.          11.5 medical Policies.
 Preauthorization is valid for up to six months.
                                                                SelectHealth has developed medical policies to serve
11.1.4 Penalties.                                               as guidelines for coverage decisions. These guidelines
                                                                detail when certain Services are considered Medically
 Failure to obtain Preauthorization of cochlear implants
                                                                Necessary or Experimental and/or Investigational
 or organ transplants will result in the denial of Benefits.
                                                                by SelectHealth. Medical policies generally apply to
11.1.5 statement of rights under the newborns’                  all of SelectHealth's fully insured Plans. Some Plans
and mothers’ Health Protection act.                             administered by SelectHealth, such as some self-
 Group health plans and health insurance issuers                funded employer plans or governmental plans, may
 generally may not, under federal law, restrict Benefits        not utilize SelectHealth's medical policies. Medical
 for any Hospital length of stay in connection with             policies do not supersede the express provisions of


                                                                                                                              seCTion 12—Claims and aPPeals
 childbirth for the mother or newborn child to less             the Certificate. Some Plans may not provide coverage
 than 48 hours following a vaginal delivery or less             for certain Services discussed in medical policies.
 than 96 hours following a cesarean section. However,           Coverage decisions are subject to all terms and
 federal law generally does not prohibit the mother’s or        conditions of the applicable Plan, including specific
 newborn’s attending Provider, after consulting with the        Exclusions and Limitations. Because medical policies
 mother, from discharging the mother or her newborn             are based on constantly changing science, they are
 earlier than 48 hours (or 96 hours as applicable).             periodically reviewed and updated by SelectHealth.
 In any case, plans and issuers may not, under federal
 law, require that a Provider obtain authorization             seCTion 12—Claims and aPPeals
 from the plan or the issuer for prescribing a length
                                                               12.1 administrative Consistency.
 of stay not in excess of 48 hours (or 96 hours).
                                                                SelectHealth will follow administrative processes
11.2 Case management.                                           and safeguards designed to ensure and to verify
 If you have certain serious or chronic conditions (such        that Benefit claim determinations are made in
 as spinal cord injuries, diabetes, asthma, or premature        accordance with the provisions of the Plan and



LE-CERT HMO 01/01/10                                                                                                     19
                                 that its provisions have been applied consistently          12.2.10 Preservice inquiry.
                                 with respect to similarly situated Claimants.                Your verbal or written inquiry to SelectHealth
                                                                                              regarding the existence of coverage for proposed
                                12.2 Claims and appeals definitions.
                                                                                              Services that do not involve a Preservice Claim, i.e.,
                                 This section uses the following additional
                                                                                              does not require prior approval for you to receive full
                                 (capitalized) defined terms:
                                                                                              Benefits. Preservice Inquiries are not claims and are
                                12.2.1 adverse benefit determination.                         not treated as Adverse Benefit Determinations.

                                 Any of the following: a denial, reduction, or termination   12.2.11 urgent Preservice Claim.
                                 of a claim for Benefits, or a failure to provide or make
                                                                                              Any Preservice Claim that, if subject to the normal
                                 payment for such a claim in whole or in part, including
                                                                                              timeframes for determination, could seriously jeopardize
                                 determinations related to a Claimant’s Eligibility, the
                                                                                              your life, health or ability to regain maximum function
                                 application of a review under SelectHealth Healthcare
                                                                                              or that, in the opinion of your treating Physician, would
                                 Management Program, and determinations that particular
                                                                                              subject you to severe pain that could not be adequately
                                 Services are Experimental and/or Investigational
                                                                                              managed without the requested Services. Whether a
                                 or not Medically Necessary or appropriate.
                                                                                              claim is an Urgent Preservice Claim will be determined by
                                12.2.2 authorized representative.                             an individual acting on behalf of SelectHealth applying
                                                                                              the judgment of a prudent layperson who possesses an
                                 Someone you have designated to represent you in the
                                 claims or appeals process. To designate an Authorized        average knowledge of health and medicine. However,
                                 Representative, you must provide written authorization       any claim that your treating Physician determines is
                                 on a form provided by the Appeals Department or              an Urgent Preservice Claim will be treated as such.
                                 Member Services. However, where an Urgent Preservice
                                 Claim is involved, a healthcare professional with           12.3 How to make a Preservice inquiry.
                                 knowledge of the medical condition will be permitted         Preservice Inquiries should be directed to Member
                                 to act as your Authorized Representative without a           Services at 801-442-5038 (Salt Lake area) or 800-538-
                                 prior written authorization. In this section, the words      5038.A Preservice Inquiry is not a claim for Benefits.
                                 you and your include your Authorized Representative.
                                                                                             12.4 How to file a Claim for benefits.
                                12.2.3 benefit determination.
                                                                                             12.4.1 Preservice Claims.
                                 The decision by SelectHealth regarding the
                                                                                              The procedure for filing most Preservice Claims
                                 acceptance or denial of a claim for Benefits.
                                                                                              (Preauthorization) is set forth in Section 11—Healthcare
                                12.2.4 Claimant.                                              Management. If there is any other Benefit that would
                                                                                              be subject to a Preservice Claim, you may file a claim
                                 Any Subscriber or Member making a claim for Benefits.
                                                                                              for that Benefit by contacting Member Services. Under
                                 Claimants may file claims themselves or may act through
                                                                                              certain circumstances provided by federal law, if you fail
                                 an Authorized Representative. In this section, the words
                                                                                              to follow the proper procedures for filing a Preservice
                                 you and your are used interchangeably with Claimant.
                                                                                              Claim, SelectHealth will provide notice of the failure and
                                12.2.5 Concurrent Care decisions.                             the proper procedures to be followed. This notification
                                 Decisions by SelectHealth regarding                          will be provided as soon as reasonably possible, but no
                                 coverage of an ongoing course of treatment                   later than five days after receipt of the claim, and may
                                 that has been approved in advance.                           be verbal unless you specifically request it in writing.

                                                                                             12.4.2 urgent Preservice Claims.
seCTion 12—Claims and aPPeals




                                12.2.6 Postservice appeal.
                                 A request to change an Adverse Benefit Determination         In order to file an Urgent Preservice Claim,
                                 for Services you have already received.                      you must provide SelectHealth with:

                                12.2.7 Postservice Claim.                                      a. information sufficient to determine to what
                                                                                                  extent Benefits are covered by the Plan; and
                                 Any claim related to Services you have already received.
                                                                                               b. a description of the medical circumstances that
                                12.2.8 Preservice appeal.                                         give rise to the need for expedited review.
                                 A request to change an Adverse Benefit
                                                                                              Under certain circumstances provided by federal
                                 Determination on a Preservice Claim.
                                                                                              law, if you fail to follow the proper procedures for
                                12.2.9 Preservice Claim.                                      filing an Urgent Preservice Claim, SelectHealth will
                                 Any claim that requires approval prior to obtaining          notify you of the failure and the proper procedures
                                 Services for you to receive full Benefits. For example,      to be followed. SelectHealth will notify you as soon
                                 a request for Preauthorization under the Healthcare          as reasonably possible, but no later than 24 hours
                                 Management program is a Preservice Claim.



                                20                                                                                               LE-CERT HMO 01/01/10
 after receiving the claim. This notice may be verbal            an extension is necessary due to your failure to submit
 unless you specifically request otherwise in writing.           the information necessary to decide the claim, the notice
                                                                 of extension will describe the required information, and
12.4.3 Postservice Claims.
                                                                 you will be given at least 45 days from your receipt
  c. Participating Providers and Facilities.                     of the notice to provide the requested information.
     Participating Providers and Facilities file Postservice
     Claims with SelectHealth and SelectHealth makes
                                                                 Notice of an Adverse Benefit Determination regarding
     payment to the Providers and Facilities.
                                                                 a Concurrent Care Decision will be provided sufficiently
  d. Nonparticipating Providers and Facilities.                  in advance of any termination or reduction of Benefits
     Nonparticipating Providers and Facilities are               to allow you to appeal and obtain a determination
     not required to file claims with SelectHealth. If
                                                                 before the Benefit is reduced or terminates.
     a Nonparticipating Provider or Facility does not
     submit a Postservice Claim to SelectHealth or              12.5.3 Postservice Claims.
     you pay the Nonparticipating Provider or Facility,
     you must submit the claim in writing in a form              Notice of Adverse Benefit Determinations will be
     approved by SelectHealth. Call Member Services              provided in writing within a reasonable period of time,
     or your employer to find out what information               but no later than 30 days after receipt of the claim.
     is needed to submit a Postservice Claim. All                However, SelectHealth may extend this period for up
     claims must be received by SelectHealth within a
                                                                 to an additional 15 days if SelectHealth: 1) determines
     36-month period from the date of the expense or
     as soon as reasonably possible. Claims received             that such an extension is necessary due to matters
     outside of this timeframe will be denied.                   beyond its control; and 2) provides you written notice,
                                                                 prior to the end of the original 30-day period, of the
12.5 Timing of benefit determinations.
                                                                 circumstances requiring the extension and the date
 SelectHealth will make and notify you of                        by which SelectHealth expects to render a decision.
 its Benefit Determinations as follows:
                                                                 The applicable time period for the Benefit
12.5.1 urgent Preservice Claims.
                                                                 Determination begins when your claim is filed
  Notice of a Benefit Determination will be provided             in accordance with SelectHealth’s procedures,
 as soon as possible, taking into account the medical            even if you have not submitted all the information
 circumstances, but no later than 72 hours after receipt         necessary to make a Benefit Determination.
 of the claim. However, if SelectHealth gives you notice of
 an incomplete claim, the notice will give you at least 48      12.6 notice of adverse benefit determinations.
 hours to provide the requested information. SelectHealth        If your claim is subject to an Adverse
 will provide a notice of Benefit Determination within           Benefit Determination, you will receive
 48 hours after receiving the specified information or           a notification that includes:
 the end of the period of time given you to provide
 the information, whichever occurs first. If the Benefit          a. The specific reason(s) for the Adverse
                                                                     Benefit Determination;
 Determination is provided verbally, it will be followed in
 writing no later than three days after the verbal notice.        b. Reference to the specific provisions on which the
                                                                     Adverse Benefit Determination was based;
 If the Urgent Preservice Claim involves a Concurrent
 Care Decision, notice of the Benefit Determination               c. A description of any additional information
                                                                     or material needed from you to complete the
 will be provided as soon as possible but no later than
                                                                     claim and an explanation of why it is necessary;
 24 hours after receipt of your claim for extension of



                                                                                                                                  seCTion 12—Claims and aPPeals
 treatment or care, as long as the claim is made at               d. If an internal rule, guideline, protocol, or other
 least 24 hours before the prescribed period of time                 similar criterion was relied upon in making the
                                                                     Adverse Benefit Determination, either the specific
 expires or the prescribed number of treatments ends.
                                                                     rule, guideline, protocol, or other similar criterion
                                                                     or a statement that such a rule, guideline, protocol,
12.5.2 other Preservice Claims.
                                                                     or other similar criterion was relied upon in the
 Notice of a Benefit Determination will be provided in               Adverse Benefit Determination and that a copy
 writing within a reasonable period appropriate to the               of the rule, guideline, protocol, or other criterion
 medical circumstances, but no later than 15 days after              will be provided upon request free of charge;
 receipt of the claim. However, SelectHealth may extend           e. If the Adverse Benefit Determination was
 this period for up to an additional 15 days if SelectHealth:        based on a Medical Necessity, Experimental and/
 1) determines that such an extension is necessary due to            or Investigational or similar Exclusion or Limitation,
 matters beyond its control; and 2) provides you written             either an explanation of the scientific or clinical
                                                                     judgment for the determination, applying the
 notice, prior to the end of the original 15-day period, of
                                                                     terms of the Plan to your medical circumstances,
 the circumstances requiring the extension and the date              or a statement that such an explanation will
 by which SelectHealth expects to render a decision. If              be provided upon request free of charge;



LE-CERT HMO 01/01/10                                                                                                         21
                                  f. If an Urgent Preservice Claim was                       Determination, whether or not the advice was relied
                                     denied, a description of the expedited review           upon in making the Adverse Benefit Determination.
                                     process applicable to the claim; and
                                                                                            12.8.2 form and Timing.
                                  g. A description of SelectHealth’s review or
                                     appeal procedures, including applicable time            All requests for a formal appeal of an Adverse Benefit
                                     limits, and a statement of your right to bring          Determination (other than those involving an Urgent
                                     suit under ERISA Section 502(a) with respect            Preservice Claim) must be in writing and should
                                     to any claim denied after an appeal.                    include a copy of the Adverse Benefit Determination
                                12.7 Problem solving.                                        and any other pertinent information that you want
                                                                                             SelectHealth to review in conjunction with your
                                 SelectHealth is committed to making sure that all
                                                                                             appeal. Send all information to the SelectHealth
                                 of your concerns or problems are investigated and
                                                                                             Appeals Department at the following address:
                                 resolved as soon as possible. Most situations can be
                                 resolved informally by a Member Services representative,                appeals department
                                                                                                         P.o. box 30192
                                 usually within seven days. Call Member Services at
                                                                                                         salt lake City, utah 84130-0192
                                 801-442-5038 (Salt Lake area) or 800-538-5038.
                                 SelectHealth offers foreign language assistance.            You may appeal an Adverse Benefit Determination
                                                                                             of an Urgent Preservice Claim on an expedited basis
                                12.8 formal appeals.                                         either verbally or in writing. You may appeal verbally
                                 If you are not satisfied with the result of working         by calling the SelectHealth Appeals Department at 801-
                                 with Member Services, you may file a written formal         442-4684 (Salt Lake area) or 800-538-5038, ext.4684.
                                 appeal of any Adverse Benefit Determination or the          If the request is made verbally, the SelectHealth
                                 negative outcome of a Preservice Inquiry. Written           Appeals Department will within 24 hours send written
                                 formal appeals should be sent to the SelectHealth           confirmation acknowledging the receipt of your request.
                                 Appeals Department. As the delegated claims review
                                                                                             You may also formally appeal the negative outcome
                                 fiduciary under your Employer’s Plan, SelectHealth
                                                                                             of a Preservice Inquiry by writing to the SelectHealth
                                 will conduct a full and fair review of your appeal and
                                                                                             Appeals Department at the address above. You should
                                 has final discretionary authority and responsibility for
                                                                                             include any information that you wish SelectHealth
                                 deciding all matters regarding Eligibility and coverage.
                                                                                             to review in conjunction with your appeal.
                                12.8.1 general rules and Procedures.
                                                                                             You must file a formal appeal within 180 days
                                 You will, upon request and free of charge, be given
                                                                                             from the date you received notification of
                                 reasonable access to, and copies of, all documents,
                                                                                             the Adverse Benefit Determination or made
                                 records, and other information relevant to your claim
                                                                                             the Preservice Inquiry, as applicable.
                                 for Benefits. You will also have the opportunity to
                                 submit written comments, documents, records, and            Appeals that do not comply with the above
                                 other information relating to your appeal. SelectHealth     requirements are not subject to review
                                 will consider this information regardless of whether it     by SelectHealth or legal challenge.
                                 was considered in the Adverse Benefit Determination.
                                                                                            12.8.3 mandatory and voluntary appeal levels.
                                 At each level in the appeal process, no deference will      As described below, the formal appeals process differs
                                 be afforded to the Adverse Benefit Determination,           for Preservice Claims and Postservice Claims. In each
                                 and decisions will be made by fiduciaries who               case, there are both mandatory and voluntary levels of
seCTion 12—Claims and aPPeals




                                 did not make the Adverse Benefit Determination              review. For purposes of the formal appeals process only,
                                 and who do not report to anyone who did. If the             Preservice Inquiries will be treated like Preservice Claims.
                                 Adverse Benefit Determination was based on medical
                                 judgment, including determinations that Services are        You must exhaust all mandatory levels of review before
                                 Experimental and/or Investigational or not Medically        you may pursue civil action under ERISA Section 502(a).
                                 Necessary, the fiduciaries at each applicable level will    It is your choice, however, whether or not to seek
                                 consult with a medical professional with appropriate        voluntary levels of review, and you are not required to do
                                 training and experience in the appropriate field of         so before pursuing civil action. SelectHealth agrees that
                                 medicine and who was neither consulted in connection        any statute of limitations or other legal defense based
                                 with the Adverse Benefit Determination nor is the           on timeliness is suspended during the time that any
                                 subordinate of such an individual. Upon request, you        voluntary appeal level is pending. Your decision whether
                                 will be provided the identification of any medical          or not to seek voluntary levels of review will have no
                                 expert(s) whose advice was obtained on behalf of            effect on your rights to any other Benefits. SelectHealth
                                 SelectHealth in connection with the Adverse Benefit         will provide you, upon request, sufficient information




                                22                                                                                              LE-CERT HMO 01/01/10
 to enable you to make an informed decision about              If your appeal involves an Urgent Preservice Claim,
 whether or not to engage in a voluntary level of review.      you may verbally request an expedited review.
                                                               You will be notified of the appeal decision on an
 a. Preservice Appeals.                                        expedited review as soon as possible, taking into
 The formal process for Preservice Appeals and                 account the medical circumstances, but no later than
 appealing the negative outcome of a Preservice                72 hours after the receipt of your appeal. A decision
 Inquiry provides one mandatory review level, two              communicated verbally will be followed up in writing.
 possible voluntary review levels, and the right to            step 3-second level voluntary review
 pursue civil action under ERISA Section 502(a).
                                                               If you are dissatisfied with the result of Step 2, and
   step 1–mandatory review                                     you do not require an expedited review, you may
   Upon receipt, your appeal will be investigated by           voluntarily request to have your appeal reviewed by
   the Appeals Department. All relevant, available             the SelectHealth Appeals Committee. Such a request
   information will be reviewed by the Appeals                 must be made in writing to the Appeals Department
   Department, the Complaint Review Committee,                 within 60 days of the date of SelectHealth’s response
   or an appropriate healthcare practitioner. The              to Step 2.You may appear in person or by telephone
   Appeals Department will notify you in writing of the        before the Appeals Committee to present any
   appeal decision within a reasonable period of time          arguments or evidence you feel is relevant to the
   appropriate to the medical circumstances, but no            matter; however, participation is not a requirement.
   later than 30 days after the receipt of your appeal.        SelectHealth will notify you of the result of the
                                                               Appeals Committee review in writing within 60
   If your appeal involves an Urgent Preservice Claim,         days of the date you requested the review.
   you may request an expedited review. You will be
   notified of the appeal decision on an expedited             Note: This level of review is not available on
   review as soon as possible, taking into account             an expedited basis. There is only one level of
   the medical circumstances, but no later than 72             voluntary review (Step 2) for Urgent Preservice
   hours after the receipt of your appeal. A decision          Claims that requires expedited review.
   communicated verbally will be followed up in writing.
                                                               The Appeals Committee may, in its sole discretion
   step 2–first level voluntary review                         and at no cost to you, seek an assessment from
   If you are dissatisfied with the decision made in           an IRO in conjunction with its decision if no
   Step 1, you may voluntarily request a review of your        such review has previously been conducted.
   appeal by the SelectHealth Grievance Committee. If          Civil action
   you are appealing an Adverse Benefit Determination
                                                               At any point after the mandatory review process
   regarding Medical Necessity, you may request
                                                               (Step 1), you may choose to pursue civil action under
   a review of your appeal by either the Grievance
                                                               ERISA Section 502(a).Failure to properly pursue the
   Committee or an Independent Review Organization
                                                               mandatory appeals process may result in a waiver of
   (IRO).You may appear in person or by telephone
                                                               the right to challenge SelectHealth’s original decision.
   before the Grievance Committee to present any
   arguments or evidence you feel is relevant to the         b. Postservice Appeals.
   matter; however, participation is not a requirement. An
   IRO is an independent, external review organization       The formal process for Postservice Appeals
                                                             provides two mandatory review levels, one


                                                                                                                          seCTion 12—Claims and aPPeals
   that is not connected in any way with SelectHealth.
   The IRO engages healthcare professionals with the         voluntary review level, and the right to pursue
   appropriate level and type of clinical knowledge          civil action under ERISA Section 502(a).
   and experience to properly judge an appeal. There           step 1–first level mandatory review
   is no cost to you for the Grievance Committee or
                                                               Upon receipt, your appeal will be investigated by
   IRO appeal. Such a request for this voluntary review
                                                               the SelectHealth Appeals Department. All relevant
   must be made in writing to the Appeals Department
                                                               information will be reviewed by the Appeals
   within 60 days for Grievance Committee review (180
                                                               Department, the Complaint Review Committee,
   days for an IRO review) from the date the Appeals
                                                               or an appropriate healthcare practitioner..The
   Department notifies you of the appeal decision. If
                                                               Appeals Department will notify you in writing of the
   you are appealing an Adverse Benefit Determination
                                                               appeal decision within a reasonable period of time
   of Medical Necessity, your request must specify
                                                               appropriate to the medical circumstances, but no
   whether the appeal is to the Grievance Committee or
                                                               later than 30 days after the receipt of your appeal.
   to an IRO. SelectHealth will notify you of the result
   of the Grievance Committee or IRO review in writing
   within 30 days of the date you requested the review.


LE-CERT HMO 01/01/10                                                                                               23
                                     step 2–second level mandatory review                         Failure to properly pursue the mandatory appeals
                                     If you are dissatisfied with the decision made in            process may result in a waiver of the right to
                                     Step 1, you may request further consideration by             challenge SelectHealth’s original decision.
                                     the SelectHealth Grievance Committee. Such a             12.8.4 notification of appeal decisions.
                                     request must be made in writing to the Appeals
                                                                                               At each applicable level of the appeals process described
                                     Department within 60 days of the date the Appeals
                                                                                               above, if your appeal is denied SelectHealth’s written
                                     Department notifies you of its appeal decision. You
                                                                                               notification will include the following information:
                                     may appear in person or by telephone before the
                                     Grievance Committee to present any arguments               a. A statement of SelectHealth’s understanding
                                     or evidence you feel are relevant to the matter;              of the pertinent facts of the appeal;
                                     however, participation is not a requirement.
                                                                                                b. The specific reason(s) for the adverse determination,
                                     SelectHealth will notify you of the result of the
                                                                                                   in easily understandable language;
                                     Grievance Committee review in writing within
                                     30 days of the date you requested the review.              c. Reference to the specific provisions on
                                                                                                   which the adverse determination was based;
                                     The Grievance Committee may, in its sole discretion
                                                                                                d. A statement regarding your right, upon
                                     and at no cost to you, seek an assessment from                request and free of charge, to access and
                                     an IRO in conjunction with its decision if no                 receive copies of documents, records, and other
                                     such review has previously been conducted.                    information that are relevant to the claim;

                                     step 3–voluntary appeals Committee review                  e. If an internal rule, guideline, protocol, or other
                                                                                                   similar criterion was relied upon in denying the
                                     If you are dissatisfied with the result of Step 2, you
                                                                                                   appeal, either the specific rule, guideline, protocol,
                                     may voluntarily request a review of your appeal               or other similar criterion or a statement that such a
                                     by the SelectHealth Appeals Committee. If you are             rule, guideline, protocol, or other similar criterion was
                                     appealing an Adverse Benefit Determination regarding          relied upon in denying the appeal and that a copy
                                     Medical Necessity, you may request a review of your           of the rule, guideline, protocol, or other criterion
                                                                                                   will be provided upon request free of charge;
                                     appeal by either the Appeals Committee or an IRO.
                                     You may appear in person or by telephone before            f. If the denied appeal was based on a Medical
                                     the Appeals Committee to present any arguments                Necessity, Experimental and/or Investigational
                                     or evidence you feel is relevant to the matter;               or similar Exclusion or Limitation, either
                                                                                                   an explanation of the scientific or clinical
                                     however, participation is not a requirement. An
                                                                                                   judgment for the denial, applying the terms
                                     IRO is an independent external review organization            of the Plan to your medical circumstances,
                                     that is not connected in any way with SelectHealth.           or a statement that such an explanation will
                                     The IRO engages healthcare professionals with the             be provided upon request free of charge;
                                     appropriate level and type of clinical knowledge
                                                                                                g. A list of titles and qualifications of the
                                     and experience to properly judge an appeal. There             individuals participating in the review; and
                                     is no cost to you for the Appeals Committee or IRO
                                     review. Your request for voluntary review must be          h. A statement describing any additional mandatory
                                                                                                   or voluntary appeal levels either required or offered
                                     made in writing to the Appeals Department within 60
                                                                                                   by SelectHealth, including the opportunity for
                                     days for Appeals Committee review, and for an IRO             IRO assessment, if applicable, your right to obtain
                                     review within 180 days from the date of SelectHealth's        information about such procedures, and a statement
                                     response to the second level mandatory review. If             of your right to bring suit under ERISA Section 502(a).
seCTion 12—Claims and aPPeals




                                     you are appealing an Adverse Benefit Determination
                                                                                                i. Notification of the decision on an Urgent Preservice
                                     of Medical Necessity, your request must specify               Claim may be provided verbally, but a follow-
                                     whether the appeal is to the Appeals Committee or             up written notification will be provided no later
                                     to an IRO. SelectHealth will notify you of the result         than three days after the verbal notice.
                                     of the Appeals Committee or IRO review in writing        12.8.5 Physical examinations/second opinions.
                                     within 60 days of the date you requested the review.
                                                                                               SelectHealth has the right to request that a Member
                                     The Appeals Committee may, in its sole discretion         be examined by an appropriate Provider chosen
                                     and at no cost to you, seek an assessment from            by SelectHealth in conjunction with an appeal.
                                     an IRO in conjunction with its decision if no             SelectHealth will pay for any such exam.
                                     such review has previously been conducted.

                                     Civil action
                                     At any point after SelectHealth’s mandatory
                                     review process (Steps 1 and 2), you may choose
                                     to pursue civil action under ERISA Section 502(a).


                                24                                                                                                 LE-CERT HMO 01/01/10
seCTion 13—oTHer Provisions                                    against, you (or your agent or attorney) for purposes of
affeCTing your benefiTs                                        collecting SelectHealth’s equitable restitution interest or
                                                               to enforce the constructive trust required by this section.
13.1 Coordination of benefits.
 When you or your Dependents have healthcare coverage          Except for proceeds obtained from uninsured or
 under more than one health benefit plan, SelectHealth         underinsured motorist coverage, this contractual
 will coordinate Benefits with the other healthcare            right of subrogation/restitution applies whether or
 coverage according to the Coordination of Benefits            not you believe that you have been made whole or
 rules set forth in Utah Code, Section 31A-22-619.             otherwise fully compensated by any recovery or
                                                               potential recovery from the third party and regardless
13.1.1 required Cooperation.
                                                               of how the recovery may be characterized, e.g., as
 You are required to cooperate with SelectHealth in            compensation for damages other than medical expenses.
 administering Coordination of Benefits. Cooperation may
 include providing notice of other health benefit coverage,    You are required to:
 copies of divorce decrees, bills and payment notices
                                                               a. promptly notify SelectHealth of all possible
 from other payers, and/or signing documents required
                                                                  subrogation/restitution situations;
 by SelectHealth to administer Coordination of Benefits.
 Failure to cooperate may result in the denial of claims.      b. help SelectHealth or its designated agent to
                                                                  assert its subrogation/restitution interest;
13.1.2 direct Payments.
                                                               c. not take any action that prejudices SelectHealth’s
 SelectHealth may make a direct payment to                        right of subrogation/restitution, including settling
 another health benefit plan when the other plan                  a dispute with a third party without protecting
 has made a payment that was SelectHealth’s                       SelectHealth’s subrogation/restitution interest;
 responsibility. This amount will be treated as though
                                                               d. sign any papers required to enable SelectHealth
 it was a Benefit paid by the Plan, and SelectHealth              to assert its subrogation/restitution interest.
 will not have to pay that amount again.
                                                               e. grant to SelectHealth a first priority
13.2 subrogation/restitution.                                     lien against the proceeds of any settlement,
                                                                  verdict, or other amounts you receive; and
 As a condition to receiving Benefits under the Plan,
 you and your Dependents (hereinafter you) agree that          f. assign to SelectHealth any benefits you
 SelectHealth is automatically subrogated to, and has a           may have under any other coverage to the
 right to receive equitable restitution from, any right of        extent of SelectHealth’s claim for restitution.




                                                                                                                              seCTion 13—oTHer Provisions affeCTing your benefiTs
 recovery you may have against any third party as the          SelectHealth’s right of subrogation/restitution exists
 result of an accident, illness, injury, or other condition    to the full extent of any payments made, Services
 involving the third party (hereinafter third-party event)     provided, or expenses incurred on your behalf because
 that causes you to obtain Covered Services that are           of or reasonably related to the third-party event.
 paid for by SelectHealth. SelectHealth is entitled to
 receive as equitable restitution the proceeds of any          You (or your agent or attorney) will be personally
 judgment, settlement, or other payment paid or payable        liable for the equitable restitution amount to the
 in satisfaction of any claim or potential claim that you      extent that SelectHealth does not recover that
 have or could assert against the third party to the extent    amount through the process described above.
 of all Benefits paid by SelectHealth or payable in the
 future by SelectHealth because of the third-party event.      If you fail to fully cooperate with SelectHealth or
                                                               its designated agent in asserting SelectHealth’s
 Any funds you (or your agent or attorney) recover by          subrogation/restitution right, then limited to the
 way of settlement, judgment, or other award from a            compensation you (or your agent or attorney) have
 third party or from your own insurance due to a third-        received from a third party, SelectHealth may reduce
 party event as described in this section shall be held        or deny coverage under the Plan and offset against any
 by you (or your agent or attorney) in a constructive          future claims. Further, SelectHealth may compromise
 trust for the benefit of SelectHealth until SelectHealth’s    with you on any issue involving subrogation/restitution in
 equitable restitution interest has been satisfied.            a way that includes your surrendering the right to receive
                                                               further Services under the Plan for the third-party event.
 SelectHealth shall have the right to intervene in any
 lawsuit, threatened lawsuit, or settlement negotiation        SelectHealth will reduce the equitable restitution
 involving a third party for purposes of asserting and         required in this section to reflect reasonable
 collecting its equitable restitution interest as described    costs or attorneys’ fees incurred in obtaining
 in this section. SelectHealth shall have the right to bring   compensation, as separately agreed to in writing
 a lawsuit against, or assert a counterclaim or cross-claim    between SelectHealth and your attorney.



LE-CERT HMO 01/01/10                                                                                                     25
                                         13.3 right of recovery.                                           15.2 Payment.
                                          SelectHealth will have the right to recover any payment           All enrollments are conditioned upon the timely payment
                                          made in excess of SelectHealth’s obligations under                of Premiums to SelectHealth by your employer.
                                          the Contract. Such recoveries are limited to a time
                                          period of 12 months (or 24 months for a Coordination
                                                                                                           15.3 Contract.
                                          of Benefits error) from the date a payment is made                The Contract is with your employer, and only your
                                          unless the recovery is due to fraud or intentional                employer can change or terminate it. Your employer
                                          material misrepresentation by you or your Dependents.             is responsible for notifying you of any changes to the
                                          This right of recovery will apply to payments made to             Plan and for providing you at least 30 days written
                                          you, your Dependents, your employer, Providers, or                notice if the Contract is terminated for any reason.
                                          Facilities. If an excess payment is made by SelectHealth
                                                                                                           15.4 Compliance.
                                          to you, you agree to promptly refund the amount of
                                          the excess. SelectHealth may, at its sole discretion,             Your employer is responsible for complying with
                                          offset any future Benefits against any overpayment.               all reporting, disclosure, and other requirements
                                                                                                            for your Employer's Plan under federal law.
                                         seCTion 14—subsCriber resPonsibiliTies
                                                                                                           seCTion 16—definiTions
                                          As a condition to receiving Benefits,
                                          you are required to pay:                                          This Certificate of Coverage contains certain defined
                                                                                                            terms that are capitalized in the text and described
                                         14.1 Payment.                                                      in this section. Words that are not defined have
                                          Pay applicable Premiums to your employer, and                     their usual meaning in everyday language.
                                          pay the Coinsurance, Copay, and/or Deductible
                                                                                                           16.1 activities of daily living.
                                          amounts listed in your Member Payment Summary
                                          to your Provider(s) and/or Facilities.                            Eating, personal hygiene, dressing, and similar
                                                                                                            activities that prepare an individual to participate
                                         14.2 Changes in eligibility or Contact information.                in work or school. Activities of Daily Living
                                          Notify your employer when there is a change in your               do not include recreational, professional,
                                          situation that may affect your Eligibility, the Eligibility of    or school-related sporting activities.
                                          your Dependents, or if your contact information changes.
                                                                                                           16.2 allowed amount.
                                          Your employer has agreed to notify us of these changes.
                                                                                                            The dollar amount allowed by SelectHealth
                                         14.3 other Coverage.                                               for a specific Covered Service.
                                          Notify SelectHealth if you or your Dependents obtain
                                                                                                           16.3 ambulatory surgical facility.
                                          other healthcare coverage. This information is necessary
                                          to accurately process and coordinate your claims.                 A Facility licensed by the state where Services
                                                                                                            are provided to render surgical treatment and
                                         14.4 information/records.                                          recovery on an outpatient basis to sick or injured
                                          Provide us all information necessary to administer                persons under the direction of a Physician. Such
seCTion 14—subsCriber resPonsibiliTies




                                          your coverage, including the medical history                      a Facility does not provide inpatient Services.
                                          and records for you and your Dependents and,
                                                                                                           16.4 annual open enrollment.
                                          if requested, your social security number(s).
                                                                                                            The period of time each year specified in by your
                                         14.5 notification of members.                                      employer during which you are given the opportunity
                                          Notify your enrolled Dependents of all                            to enroll yourself and your Dependents in the Plan.
                                          Benefit and other Plan changes.
                                                                                                           16.5 benefit rider.
                                         seCTion 15—emPloyer resPonsibiliTies                               Additional coverage purchased by your employer
                                                                                                            as noted in your Member Payment Summary
                                         15.1 enrollment.
                                                                                                            that modifies Limitations and/or Exclusions.
                                          Your employer makes initial Eligibility decisions and
                                          communicates them to SelectHealth. SelectHealth                  16.6 benefit(s).
                                          reserves the right to verify that the Eligibility                 The payments and privileges to which you are
                                          requirements of the Contract are satisfied. Your                  entitled by this Certificate and the Contract.
                                          employer is obligated to promptly notify us whenever
                                          there is a change in your situation that may affect              16.7 Certificate of Coverage (Certificate).
                                          your Eligibility or the Eligibility of your Dependents.           This document, which describes the terms and
                                          This includes FMLA and other leaves of absence.                   conditions of the health insurance Benefits provided



                                         26                                                                                                    LE-CERT HMO 01/01/10
 by your employer’s Group Health Insurance Contract            16.18 dependents.
 with SelectHealth. Your Member Payment Summary is              Your lawful spouse and any child who meets
 attached to and considered part of this Certificate.           the Eligibility criteria set forth in Section
                                                                2—Eligibility and the Group Application.
16.8 Cobra Coverage.
 Coverage required by the Consolidated Omnibus                 16.19 diagnostic Tests, major.
 Budget Reconciliation Act of 1985 (COBRA).                     Diagnostic tests categorized as major by
                                                                SelectHealth. SelectHealth categorizes tests based
16.9 Coinsurance.
                                                                on several considerations such as the invasiveness
 A percentage of the Allowed Amount stated in your
                                                                and complexity of the test, the level of expertise
 Member Payment Summary that you must pay for
                                                                required to interpret or perform the test, and
 Covered Services to the Provider and/or Facility.
                                                                where the test is commonly performed. Examples
16.10 Continuation Coverage.                                    of common Major Diagnostic Tests are:

 COBRA Coverage and/or Utah mini-COBRA Coverage.                 a. imaging studies such as MRIs, CT scans, and PET scans

16.11 Contract.                                                  b. neurologic studies such as EMGs and
                                                                    nerve conduction studies
 The Group Health Insurance Contract between
 SelectHealth and your employer.                                 c. cardiovascular procedures such
                                                                    as coronary angiograms
16.12 Conversion Coverage.
                                                                 d. gastrointestinal procedures such as
 A separate, individual policy you may have the
                                                                    EGDs, ERCPs, and colonoscopies
 right under Utah law to obtain after your coverage
 under the group Contract is terminated.                         e. gene-based testing and genetic testing

16.13 Copay (Copayment).                                        If you have a question about the category of a particular
                                                                test, please contact SelectHealth Member Services.
 A fixed amount stated in your Member
 Payment Summary that you must pay for                         16.20 diagnostic Tests, minor.
 Covered Services to a Provider or Facility.
                                                                Tests not categorized as Major Diagnostic Tests
16.14 Covered services.                                         are considered Minor Diagnostic Tests. Examples
                                                                of common Minor Diagnostic Tests are:
 The Services listed in Section 8—Covered Services
 and applicable Benefit Riders and not excluded                  a. bone density tests
 in Section 10—Limitations and Exclusions.
                                                                 b. certain EKGs
16.15 Custodial Care.
                                                                 c. echocardiograms
 Services provided primarily to maintain rather than
 improve a Member’s condition or for the purpose of              d. routine blood and urine tests
 controlling or changing the Member's environment.               e. simple x-rays such as chest and long bone x-rays
 Services requested for the convenience of the Member
 or the Member’s family that do not require the training         f. spirometry/pulmonary function testing
 and technical skills of a licensed Nurse or other licensed    16.21 durable medical equipment (dme).
 Provider, such as convalescent care, rest cures, nursing
                                                                Medical equipment that is able to withstand
 home services, etc. Services that are provided principally
                                                                repeated use and is generally not useful in
 for personal hygiene or for assistance in daily activities.
                                                                the absence of an illness or injury.
16.16 deductible(s).
                                                               16.22 effective date.
                                                                                                                             seCTion 16—definiTions


 An amount stated in your Member Payment Summary
                                                                The date on which coverage for you and/
 that you must pay each Year for Covered Services before
                                                                or your Dependents begins.
 SelectHealth makes any payment. Some categories
 of Benefits may be subject to separate Deductibles.           16.23 eligible, eligibility.
16.17 dental services.                                          In order to be Eligible, you or your Dependents
                                                                must meet the criteria for participation specified in
 Services rendered to the teeth, the tooth pulp, the
                                                                Section 2—Eligibility and in the Group Application.
 gums, or the bony structure supporting the teeth.
                                                               16.24 emergent Condition(s).
                                                                A condition of recent onset and sufficient severity,
                                                                including severe pain, that would lead a prudent


LE-CERT HMO 01/01/10                                                                                                    27
                          layperson, possessing an average knowledge of                    and defined by federal regulations, particularly
                          medicine and health, to reasonably expect that failure           those of the FDA or the Department of
                                                                                           Health and Human Services (HHS); or
                          to obtain immediate medical care could result in:
                                                                                         e. If the predominant opinion among appropriate
                          a. placing the Member’s health in serious jeopardy;               experts as expressed in the peer-reviewed medical
                                                                                            literature is that further research is necessary in
                          b. placing the health of a pregnant woman or
                                                                                            order to define safety, toxicity, effectiveness, or
                             her unborn child in serious jeopardy;
                                                                                            comparative effectiveness, or there is no clear medical
                          c. serious impairment to bodily functions; or                     consensus about the role and value of the Service.

                          d. serious dysfunction of any bodily organ or part.          16.32 facility.
                                                                                        An institution that provides certain healthcare
                         16.25 employer waiting Period.
                                                                                        Services within specific licensure requirements.
                          The period that you must wait after becoming Eligible
                          for coverage before your Effective Date. Subject to          16.33 generic drug(s).
                          approval by SelectHealth, your employer specifies             A medication that has the same active ingredients,
                          the length of this period in the Group Application.           safety, dosage, quality, and strength as its
                                                                                        brand-name counterpart. Both the brand-name
                         16.26 employer’s Plan.
                                                                                        drug and the Generic Drug must get approval
                          The group health plan sponsored by your                       from the FDA before they can be sold.
                          employer and insured under the Contract.
                                                                                       16.34 group application.
                         16.27 endorsement.
                                                                                        A form used by SelectHealth both as an application
                          A document that amends the Contract.                          for coverage by your employer and to specify group-
                         16.28 erisa.                                                   specific details of coverage. The Group Application may
                                                                                        contain modifications to the language of the Contract.
                          The Employee Retirement Income Security Act (ERISA),
                                                                                        It also demonstrates your employer’s acceptance of the
                          a federal law governing employee benefit plans.
                                                                                        Contract. Other documents, such as Endorsements, may
                         16.29 excess Charges.                                          be incorporated by reference into the Group Application.

                          Charges from Providers and Facilities that exceed            16.35 group Health insurance Contract.
                          SelectHealth’s Allowed Amount for Covered Services.
                                                                                        The agreement between your employer and
                          You are responsible to pay for Excess Charges from
                                                                                        SelectHealth that contains the terms and conditions
                          Nonparticipating Providers and Facilities. These charges
                                                                                        under which SelectHealth provides group
                          do not apply to your Out-of-Pocket Maximum.
                                                                                        insurance coverage to you and your Dependents.
                         16.30 exclusion(s).                                            The Group Application and this Certificate are
                                                                                        part of the Group Health Insurance Contract.
                          Situations and Services that are not covered by
                          SelectHealth under the Plan. Most Exclusions                 16.36 Healthcare management Program.
                          are set forth in Section 10—Limitations and
                                                                                        A program designed to help you obtain quality,
                          Exclusions, but other provisions throughout this
                                                                                        cost-effective, and medically appropriate care, as
                          Certificate and the Contract may have the effect
                                                                                        described in Section 11—Healthcare Management.
                          of excluding coverage in particular situations.
                                                                                       16.37 Home Healthcare.
                         16.31 experimental and/or investigational.
                                                                                        Services provided to Members at their home by a
                          A Service for which one or more of the following apply:
                                                                                        licensed Provider who works for an organization that
                          a. It cannot be lawfully marketed without the                 is licensed by the state where Services are provided.
seCTion 16—definiTions




                             approval of the Food and Drug Administration
                             (FDA) and such approval has not been granted              16.38 Hospice Care.
                             at the time of its use or proposed use;                    Supportive care provided on an inpatient or outpatient
                                                                                        basis to a terminally ill Member not expected to live
                          b. It is the subject of a current investigational new drug
                             or new device application on file with the FDA;            more than six months. May also be provided to the
                                                                                        Member’s immediate family at the family’s expense.
                          c. It is being provided pursuant to a Phase I
                             or Phase II clinical trial or as the experimental         16.39 Hospital.
                             or research arm of a Phase III clinical trial;
                                                                                        A Facility that is licensed by the state in which Services
                          d. It is being or should be delivered or provided             are provided that is legally operated for the medical
                             subject to the approval and supervision of an              care and treatment of sick or injured individuals.
                             Institutional Review Board (IRB) as required



                         28                                                                                                LE-CERT HMO 01/01/10
 A Facility that is licensed and operating                        a separate Lifetime Maximum. Lifetime Maximums
 within the scope of such license, which:                         are specified in your Member Payment Summary.

  a. operates primarily for the admission, acute care, and       16.44 limitation(s).
     treatment of injured or sick persons as inpatients;
                                                                  Situations and Services in which coverage is limited
  b. has a 24-hour-a-day nursing service by or under              by SelectHealth under the Plan. Most Limitations
     the supervision of a graduate registered Nurse               are set forth in Section 10—Limitations and
     (R.N.) or a licensed practical Nurse (L.P.N.);               Exclusions, but other provisions throughout this
  c. has a staff of one or more licensed                          Certificate and the Contract may have the effect
     Physicians available at all times; and                       of limiting coverage in particular situations.

  d. provides organized facilities for diagnosis and             16.45 limiting age.
     surgery either on its premises or in facilities available
                                                                  The maximum age for Dependent coverage,
     to the Hospital on a contractual prearranged basis.
                                                                  as set forth in the Group Application.
16.40 infertility.
                                                                 16.46 medical director.
 The inability to become pregnant or impregnate.
                                                                  The Physician(s) designated as such by SelectHealth.
16.41 injectable drugs and specialty medications.
                                                                 16.47 medical necessity/medically necessary.
 A class of drugs that may be administered orally, as a
 single injection, intravenous infusion or in an inhaled/         Services that a prudent healthcare professional
 nebulizer solution. Injectable drugs and specialty               would provide to a patient for the purpose of
 medications include all or some of the following:                preventing, diagnosing, or treating an illness, injury,
                                                                  disease, or its symptoms in a manner that is:
  a. Are often products of a living organism or
     produced by a living organism through genetic                a. in accordance with generally accepted standards
     manipulation of the organism’s natural function                 of medical practice in the United States;

  b. Are generally used to treat an ongoing chronic illness       b. clinically appropriate in terms of type,
                                                                     frequency, extent, site, and duration; and
  c. Require special training to administer
                                                                  c. not primarily for the convenience of the
  d. Have special storage and handling requirements                  patient, Physician, or other Provider.

  e. Are typically limited in their supply and                    When a medical question-of-fact exists, Medical
     distribution to patients or Providers
                                                                  Necessity shall include the most appropriate available
  f. Often have additional monitoring requirements                supply or level of service for the Member in question,
                                                                  considering potential benefit and harm to the Member.
 Certain drugs used routinely in a Provider’s office
 to treat common medical conditions (such as                      Medical Necessity is determined by the treating
 intramuscular penicillin) are not considered Injectable          Physician and by SelectHealth’s Medical Director or
 Drugs and Specialty Medications, because they                    his or her designee. The fact that a Provider or Facility,
 are widely available, distributed without limitation,            even a Participating Provider or Facility, may prescribe,
 and are not the product of bioengineering.                       order, recommend, or approve a Service does not make
                                                                  it Medically Necessary, even if it is not listed as an
16.42 initial eligibility Period.
                                                                  Exclusion or Limitation.FDA approval, or other regulatory
 The period determined by SelectHealth and your                   approval, does not establish Medical Necessity.
 employer during which you may enroll yourself and
 your Dependents in the Plan. The Initial Eligibility            16.48 member.
 Period is identified in the Group Application.                   You and your Dependents, when properly enrolled
                                                                                                                                 seCTion 16—definiTions

                                                                  in the Plan and accepted by SelectHealth.
16.43 lifetime maximum.
 The maximum accumulated amount that SelectHealth                16.49 member Payment summary.
 will pay for Covered Services rendered to a Member               A summary of your Benefits by category of service,
 during that Member's lifetime. This includes all                 attached to and considered part of this Certificate.
 amounts paid on behalf of the Member under any
 prior health benefit plans insured by SelectHealth              16.50 miscellaneous medical supplies (mms).
 (including those sponsored by former employers)                  Supplies that are disposable or
 or any of its affiliated or subsidiary companies. In             designed for temporary use.
 addition, some categories of Benefits are subject to




LE-CERT HMO 01/01/10                                                                                                        29
                         16.51 nonparticipating (out-of-network) facility.           16.61 Participating (in-network) Providers.
                          Healthcare Facilities that are not under                    Providers under contract with SelectHealth
                          contract with SelectHealth.                                 to accept Allowed Amounts as payment
                                                                                      in full for Covered Services.
                         16.52 nonparticipating (out-of-
                         network) Pharmacies.                                        16.62 Pervasive developmental disorder
                          Pharmacies that are not under                              (Pdd/developmental delay).
                          contract with SelectHealth.                                 A state in which an individual has not reached certain
                                                                                      developmental milestones normal for that individual’s
                         16.53 nonparticipating (out-of-network) Provider.            age, yet no obvious medical diagnosis or condition has
                          Providers that are not under contract with SelectHealth.    been identified that could explain the cause of this delay.
                                                                                      PDD includes five disorders characterized by delays in
                         16.54 nurse.
                                                                                      the development of multiple basic functions, including
                          A graduate Registered Nurse (R.N.) or Licensed              socialization and communication.PDD includes:
                          Practical Nurse (L.P.N.) who is licensed by the state
                                                                                       • Autistic Disorder
                          where Services are provided to provide medical care
                                                                                       • Rett's Disorder
                          and treatment under the supervision of a Physician.
                                                                                       • Childhood Disintegrative Disorder
                         16.55 office surgery, major.                                  • Asperger's Syndrome
                                                                                       • Pervasive developmental disorder
                          Surgical and endoscopic procedures in a Provider’s             not otherwise specified.
                          office for which SelectHealth’s Allowed Amount
                          is more than the dollar threshold indicated                16.63 Physician.
                          in your Member Payment Summary.                             A doctor of medicine or osteopathy who is licensed
                                                                                      by the state in which he or she provides Services and
                         16.56 office surgery, minor.                                 who practices within the scope of his or her license.
                          Surgical and endoscopic procedures in a
                          Provider’s office for which SelectHealth’s                 16.64 Plan.
                          Allowed Amount is less than the dollar threshold            The specific combination of Covered Services,
                          indicated in your Member Payment Summary.                   Limitations, Exclusions, and other requirements
                                                                                      agreed upon between SelectHealth and your employer
                         16.57 out-of-Pocket maximum.                                 as set forth in this Certificate and the Contract.
                          The maximum amount specified in your Member Payment
                          Summary that you must pay each Year to Providers and/      16.65 Plan sponsor.
                          or Facilities as Deductibles, Copays, and Coinsurance.      As defined in ERISA. The Plan Sponsor
                          Except when otherwise noted in your Member Payment          is typically your employer.
                          Summary, SelectHealth will pay 100 percent of Allowed
                                                                                     16.66 Preauthorization.
                          Amounts during the remainder of the Year once the
                          Out-of-Pocket Maximum is satisfied. Some categories         Prior approval from SelectHealth for certain Services.
                          of Benefits may be subject to separate Out-of-Pocket        Refer to Section 11—Healthcare Management
                          Maximums. Payments you make for Excess Charges,             and your Member Payment Summary.
                          non-Covered Services, and any other categories of
                                                                                     16.67 Premium(s).
                          Services specified in your Member Payment Summary
                          are not applied to the Out-of-Pocket Maximum.               The amount your Employer periodically pays
                                                                                      to SelectHealth as consideration for providing
                         16.58 Participating (in-network) benefits.                   Benefits under the Plan. The Premium is
                          Benefits available to you when you obtain Covered           specified in the Group Application.
seCTion 16—definiTions




                          Services from a Participating Provider or Facility.
                                                                                     16.68 Prescription drugs.
                         16.59 Participating (in-network) facility.                   Drugs and medications, including insulin, that by law
                          Facilities under contract with SelectHealth                 must be dispensed by a licensed pharmacist or Physician
                          to accept Allowed Amounts as payment                        and that require a Physician's written prescription.
                          in full for Covered Services.
                                                                                     16.69 Preventive services.
                         16.60 Participating (in-network) Pharmacies.                 Certain examinations, procedures, immunizations,
                          Pharmacies under contract with SelectHealth                 screenings, x-rays, and laboratory tests that can
                          to accept Allowed Amounts as payment                        detect disease conditions not known to currently
                          in full for Covered Services.                               exist, or which, in the case of immunizations,
                                                                                      prevent the development of disease.


                         30                                                                                              LE-CERT HMO 01/01/10
16.70 Primary Care Physician or                                Lake, Sanpete, Sevier, Summit, Tooele, Uintah, Utah,
Primary Care Provider (PCP).                                   Wasatch, Washington, Wayne, and Weber. However,
 A general practitioner who attends to common                  not all ZIP codes within these counties are included.
 medical problems, provides Preventive Services, and           The following ZIP codes are not part of the Select
 health maintenance. The following types of Physicians         Care Service Area: 84034, 84083, 84313, and 84329.
 and Providers, and their associated physician
                                                               Select Med Service Area. The following counties: Beaver,
 assistants and nurse practitioners, are PCPs:
                                                               Box Elder, Cache, Davis, Duchesne, Garfield, Iron, Juab,
  • Certified Nurse Midwives                                   Millard, Morgan, Piute, Salt Lake, Sanpete, Sevier, Summit,
  • Family Practice                                            Tooele, Uintah, Utah, Wasatch, Washington, Wayne, and
  • Geriatrics                                                 Weber. However, not all ZIP codes within these counties
  • Internal Medicine                                          are included. The following ZIP codes are not part of
  • Obstetrics and Gynecology (OB/GYN)                         the Select Med Service Area: 84008, 84034, 84035,
  • Pediatrics                                                 84078, 84079, 84083, 84313, 84329, 84712, 84716, 84717,
16.71 Private duty nursing.                                    84718, 84723,84734, 84736, 84759, 84764, and 84776.

 Services rendered by a Nurse to prepare and educate
                                                               Select Value Service Area. The following counties:
 family members and other caregivers on proper
                                                               Davis, Salt Lake, Summit, Utah, and Weber. However,
 procedures for care during the transition from an
                                                               not all ZIP codes within these counties are included.
 acute Hospital setting to the home setting. These
                                                               As of January 2006, the following ZIP codes are
 Services must improve, rather than maintain, your
                                                               not part of the Select Value Service Area: 84017,
 health condition and require the skills of a Nurse
                                                               84024, 84033, 84036, 84055, 84061, 84013, 84626,
 in order to be provided safely and effectively.
                                                               84651, 84653, 84655, 84660, and 84633.
16.72 Provider.
                                                              16.77 service(s).
 A vendor of healthcare Services licensed by
                                                               Services, care, tests, treatments, drugs,
 the state where Services are provided and that
                                                               medications, supplies, or equipment.
 provides Services within the scope of its license.
                                                              16.78 skilled nursing facility.
16.73 Qualified medical Child support order.
                                                               A Facility that provides Services that improve,
 A court order for the medical support
                                                               rather than maintain, your health condition,
 of a child as defined in ERISA.
                                                               that requires the skills of a Nurse in order to be
16.74 respite Care.                                            provided safely and effectively, and that:

 Care provided primarily for relief or rest                     a. Is being operated as required by law;
 from caretaking responsibilities.
                                                                b. Is primarily engaged in providing, in addition to
16.75 secondary Care Physician or                                  room and board accommodations, skilled nursing
secondary Care Provider (sCP).                                     care under the supervision of a Physician;

 Physicians and other Providers who are not                     c. Provides 24 hours a day, seven days a week
 a Primary Care Physician or Primary Care                          nursing service by or under the supervision
 Provider. Examples of an SCP include:                             of a Registered Nurse (R.N.); and

  • Cardiologists                                               d. Maintains a daily medical record of each patient.
  • Dermatologists
                                                               A Skilled Nursing Facility is not a place that is primarily
  • Neurologists
                                                               used for rest or for the care and treatment of mental
  • Ophthalmologists
                                                               diseases or disorders, Chemical Dependency, alcoholism,
  • Orthopedic Surgeons
                                                                                                                             seCTion 16—definiTions

                                                               Custodial Care, nursing home care, or educational care.
  • Otolaryngologists (ENTs)

16.76 service area.                                           16.79 special enrollment right.
 The geographical area in which SelectHealth arranges          An opportunity to enroll in the Plan outside of your
 for Covered Services for Members from Participating           employer's Annual Open Enrollment period under defined
 Providers and Facilities. Contact SelectHealth for Service    circumstances described in Section 3—Enrollment.
 Area information if the U.S. Postal Service changes
                                                              16.80 subscriber.
 or adds ZIP codes after the beginning of the Year.
                                                               You, the individual with an employment or another
 Select Care Service Area. The following counties:             defined relationship to the Plan Sponsor, through whom
 Beaver, Box Elder, Cache, Davis, Duchesne, Garfield,          Dependents may be enrolled with SelectHealth.
 Iron, Juab, Kane, Millard, Morgan, Piute, Rich, Salt


LE-CERT HMO 01/01/10                                                                                                   31
                         16.81 subscriber application.
                          The form on which you apply for
                          coverage under the Plan.

                         16.82 urgent Condition(s).
                          An acute health condition with a sudden, unexpected
                          onset that is not life threatening but that poses a danger
                          to a person's health if not attended by a Physician
                          within 24 hours, e.g., high fevers, possible fractures.

                         16.83 utah mini-Cobra.
                          Continuation coverage required by Utah law for
                          employers with fewer than 20 employees.

                         16.84 year.
                          Benefits are calculated on either a calendar-
                          year or plan-year basis, as indicated on
                          your Member Payment Summary.

                          a. The calendar year begins on January 1 at 12:00 a.m.
                             Mountain Standard Time and ends on December
                             31, at 11:59 p.m. Mountain Standard Time.

                          b. The plan Year, if applicable, is indicated
                             in the Group Application.
seCTion 16—definiTions




                         32                                                            LE-CERT HMO 01/01/10
appendix A
prescription drug list
[Appendix A—rxselect
prescription drug list—categorized
  This list contains the most commonly prescribed drugs in their most common strengths and formulations. The tiers
  determine the amount you are responsible to pay. This amount can be found on your ID card or on your Member
  Payment Summary (MPS) or Schedule of Benefits. This list does not include injectable drug benefits. Please refer to
  your member materials or contact Member Services at the number below for injectable drug information.

  This is not a complete list of all drugs and may change due to new drugs, therapies, or other factors. If you have
  any questions about your prescription drug benefits, please call Member Services at 801-442-5038 (Salt Lake area)
  or 800-538-5038 weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m. For the most
  current information regarding drug coverage, use the drug look-up tool available at www.selecthealth.org.

AllerGY ..................................................... 2   cHOlesterOl ........................................... 3         MiGrAine .................................................... 5
    ANTIHISTAMINES
                                                                  cOntrAceptiOn (BirtH cOntrOl) ..... 3                             MUscle relAxAnts ................................. 5
    NASAL PREPARATIONS
                                                                  derMAtOlOGicAls (sKin) ...................... 3                   OncOlOGics/HeMAtOlOGY ................... 5
AntiBiOtics ............................................... 2
                                                                     ACNE
    CEPHALOSPORINS                                                                                                                  OpHtHAlMics (eYe) ................................. 5
                                                                     ANTIFUNGALS
    MACROLIDES                                                                                                                         ANTI-INFECTIVES
                                                                     ANTIPSORIATICS
    MISC. ANTIBIOTICS                                                                                                                  MISC. OPHTHALMICS
                                                                     MISC. DERMATOLOGICALS
    PENICILLINS                                                                                                                        PROSTAGLANDINS
                                                                     STEROIDS
    QUINOLONES                                                                                                                      OsteOpOrOsis treAtMents ................. 5
    TETRACYCLINES                                                 diABetic .....................................................4
                                                                      INJECTABLE AND OTHER                                          Otic prepArAtiOns (eAr) .....................6
AntiFUnGAls ............................................ 2
                                                                      ORAL ANTIDIABETICS                                            pAin MedicAtiOns ...................................6
AntiVirAls ................................................ 2                                                                           NARCOTIC ANALGESICS
                                                                  GAstrOintestinAl (diGestiVe) ...........4
AnxietY & sleep disOrder ................... 2                       MISC. GASTROINTESTINAL                                             NON-STEROIDAL ANTI-
                                                                     NAUSEA & VOMITING                                                  INFLAMMATORIES
AstHMA....................................................... 2
                                                                     ULCER TREATMENTS                                               prenAtAl VitAMins .................................6
cArdiOVAscUlAr .................................... 2
                                                                  HOrMOne replAceMent tHerApY ......4                               prOstAte ...................................................6
   ACE INHIBITORS
                                                                     FEMALE
   ALPHA- 1 BLOCKERS                                                                                                                seiZUre disOrder ...................................6
                                                                     MALE
   ANGIOTENSIN II RECEPTOR
                                                                                                                                    sMOKinG cessAtiOn................................6
   BLOCKERS                                                       iMMUnOsUppressAnts ...........................4
   ANTIADRENERGICS                                                                                                                  sterOids ....................................................6
                                                                  MentAl HeAltH ........................................ 5
   BETA-BLOCKERS
                                                                     ADHD (ATTENTION DEFICIT &                                      tHYrOid .....................................................6
   BLOOD MODIFIERS
                                                                     HYPERACTIVITY)
   CALCIUM CHANNEL BLOCKERS                                                                                                         UrinArY incOntinence .........................6
                                                                     ALZHEIMERS
   CARDIAC GLYCOSIDES                                                                                                               UncAteGOriZed .......................................6
                                                                     ANTIDEPRESSANTS
   COMBINATIONS/OTHER
                                                                     ANTIPSYCHOTICS
   DIURETICS (WATER PILLS)




  tier 1 includes generic drugs                                     (Ql) Quantity limits—Quantity                                      (Brand name)—Drug names italicized
                                                                    limitations apply to certain drugs                                 in parentheses, such as (Nizoral),
  tier 2 includes preferred
                                                                    (maximum number of tablets/                                        indicate a brand-name equivalent to
  brand-name drugs
                                                                    capsules, etc. per prescription).                                  the generic drug listed.
  tier 3 includes non-preferred                                     Preauthorization is required if the
  brand-name drugs                                                                                                                     SelectHealth refers to many of the
                                                                    medication exceeds the plan limits.
                                                                                                                                       drugs in this list by their respective
  tier 4 specialty medications                                      (Gs) GenericsamplesM—The Rx copay                                  trademarks, but SelectHealth does
  (pA) preauthorization—Coverage of                                 will be eliminated for the first fill of                           not own those trademarks; the
  certain drugs is based on medical                                 certain strengths at the pharmacy.                                 manufacturer or supplier of each
  necessity. For these drugs, you will need                                                                                            drug owns the drug’s trademark. By
                                                                    (M) Maintenance drug—Available for
  preauthorization from SelectHealth;                                                                                                  listing these drugs, SelectHealth does
                                                                    90-day maintenance drug benefit
  otherwise, you will be responsible to                                                                                                not endorse or sponsor any drug,
                                                                    (not available on all plans; refer to
  pay the drug’s full retail price.                                                                                                    manufacturer, or supplier. And these
                                                                    your Member Payment Summary for
                                                                                                                                       manufacturers and suppliers do not
  (st) step therapy—Drugs that                                      coverage information).
                                                                                                                                       endorse or sponsor any SelectHealth
  require step therapy are covered by                               [Generic nAMe]—Drug names in                                       service or plan and are not affiliated
  SelectHealth only after you have tried                            brackets, such as [QUINAPRIL],                                     with SelectHealth.
  the alternative therapy, and it didn’t                            indicate a generic equivalent to the
  work (the therapy failed).                                        brand-name drug listed is available.
                                                                    Not all generic drugs will be listed.



RXSELECT PDL 01/01/10                                                                                                                                                                             1
AllerGY                                                                       ZYVOX .......................................................Tier 3           FLURAZEPAM               (Dalmane) ............................Tier       1

AntiHistAMines                                                                                                                                              HYDROXYZINE                (Vistaril) .............................Tier   1
                                                                              penicillins
ALLEGRA           [FEXOFENADINE].........................Tier             3                                                                                 LORAZEPAM              (Ativan) ..................................Tier    1
                                                                              AMOX TR-K CLAV                   (Augmentin)      .................Tier 1
ALLEGRA-D .............................................Tier 3                                                                                               LUNESTA         (QL) (ST)      .....................................Tier 3
                                                                              AMOXICILLIN              (GS)   .....................................Tier 1
CLARINEX .................................................Tier 3                                                                                            ROZEREM          (QL) ...........................................Tier     2
                                                                              AMOXIL ........................................................Tier 1
CLARINEX-D ............................................Tier 3                                                                                               SONATA        [ZALEPON] (QL) (ST) ......................Tier              3
                                                                              AMPICILLIN ................................................Tier 1
FEXOFENADINE                  (Allegra) ..........................Tier    1                                                                                 TEMAZEPAM              (Restoril) ................................Tier    1
                                                                              AUGMENTIN             (Amox Tr-K Clav) .....................Tier          3
XYZAL (QL) ..................................................Tier 3                                                                                         XANAX        [ALPRAZOLAM] ................................Tier            3
                                                                              AUGMENTIN XR .......................................Tier 2
                                                                                                                                                            XANAX XR            [ALPRAZOLAM ER] (QL) .............Tier                3
nAsAl prepArAtiOns                                                            MOXATAG           (QL) ...........................................Tier    3
                                                                                                                                                            ZOLIPIDEM           (Ambien) (QL) ............................Tier        1
ASTELIN         (M) ...............................................Tier   2   PENICILLIN .................................................Tier 1
                                                                                                                                                            ZALEPON          (Sonata) (QL)       ...............................Tier 1
ASTEPRO           (M) .............................................Tier   2   TRIMOX ........................................................Tier 1

ATROVENT             [IPRATROPIUM] (M) ...................Tier            3   QUinOlOnes                                                                    AstHMA
                                                                                                                                                            ACCOLATE            (M) (QL) ...................................Tier      2
BECONASE AQ                 (M)   ..................................Tier 3    AVELOX .....................................................Tier 3
                                                                                                                                                            ADVAIR       (M)    ................................................Tier 2
FLONASE           [FLUTICASONE] (M)          .....................Tier 3      CIPRO      [CIPROFLOXACIN]           ..............................Tier 3
                                                                                                                                                            ALBUTEROL [VENTOLIN] (M) ......................Tier 1
FLUNISOLIDE              (Nasarel) (M) .........................Tier      1   CIPRO XR         [CIPROFLOXACIN ER] ...................Tier               3   ASMANEX (M) (QL) .....................................Tier 2
FLUTICASONE                (Flonase) (M) (GS)       ...............Tier 1     CIPROFLOXACIN                   (Cipro) ...........................Tier   1   ATROVENT HFA                  (M) .................................Tier   3
IPRATROPIUM               (Atrovent) (M) ......................Tier       1   CIPROFLOXACIN ER                     (Cipro XR)................Tier       1   AZMACORT             (M) .........................................Tier    3
NASACORT AQ                 (M)   ..................................Tier 3    LEVAQUIN ................................................Tier 3               BROVANA            (QL) (M) .....................................Tier     3
NASAREL           [FLUNISOLIDE] (M)         ......................Tier 3
                                                                              tetrAcYclines                                                                 COMBIVENT             (M) ........................................Tier    3
NASONEX            (M) ............................................Tier   2
                                                                              DORYX        (ST) .................................................Tier   3   CROMOLYN             (Intal) (M) .................................Tier    1
OMNARIS ..................................................Tier 3
                                                                              DOXYCYCLINE               (Vibramycin) (GS)        ................Tier 1     FLOVENT HFA               (M) ....................................Tier    2
RHINOCORT AQUA                      (M) ...........................Tier   3
                                                                              MINOCYCLINE               (Dynacin/Minocin)        ................Tier 1     FORADIL         (M) ..............................................Tier    3
VERAMYST             (M) ..........................................Tier   3
                                                                              PERIOSTAT           [DOXYCYCLINE] (ST) .................Tier              3   MAXAIR        (M) ................................................Tier    2
AntiBiOtics                                                                   SOLODYN           (ST)   ...........................................Tier 3    PROAIR HFA             (M)   .......................................Tier 2

cepHAlOspOrins                                                                TETRACYCLINE (Sumycin) ..........................Tier 1                       PROVENTIL HFA                  (M) ................................Tier   3

CEDAX .......................................................Tier 3                                                                                         PULMICORT             (M) .........................................Tier   2
                                                                              AntiFUnGAls                                                                   QVAR      (M) .....................................................Tier   2
CEFACLOR            (Ceclor) .....................................Tier    1   CLOTRIMAZOLE                 (Mycelex) .........................Tier      1
CEFADROXIL              (Duricef) ................................Tier    1                                                                                 SEREVENT            (M) ...........................................Tier   2
                                                                              DIFLUCAN           150mg

CEFDINIR          (Omnicef) .....................................Tier     1   [FLUCONAZOLE 150mg](QL) ..............................Tier                3   SINGULAIR 10 mg                  (ST) (QL) (M)    ...............Tier 2

CEFPROZIL            (Cefzil)   .....................................Tier 1   DIFLUCAN           [FLUCONAZOLE] ........................Tier             3   SINGULAIR 4 mg and 5 mg                          (QL) (M) ....Tier        2

CEFUROXIME               (Ceftin) .................................Tier   1   FLUCONAZOLE                 150mg                                             SPIRIVA      (QL) (M)     .........................................Tier 2
                                                                              (Diflucan 150mg) (QL).........................................Tier        1   SYMBICORT             (M) .........................................Tier   2
CEFZIL       [CEFPROZIL]        ....................................Tier 3
                                                                              FLUCONAZOLE                 (Diflucan) ..........................Tier     1   THEOPHYLLINE (M)...................................Tier 1
CEPHALEXIN              (Keflex)   .................................Tier 1
                                                                              ITRACONAZOLE                  (Sporanox) (QL) (PA) ........Tier           1   UNIPHYL        (M) ...............................................Tier    2
KEFLEX         [CEPHALEXIN].................................Tier          3
                                                                              KETOCONAZOLE                    (Nizoral) ........................Tier    1   VENTOLIN HFA                 (M) ..................................Tier   2
OMNICEF           [CEFDINIR] ..................................Tier       3
                                                                              LAMISIL       [TERBINAFINE] (QL) ........................Tier             3   XOPENEX          (M) .............................................Tier    3
SUPRAX .....................................................Tier 3
                                                                              MYCELEX          [CLOTRIMAZOLE] .........................Tier             3   XOPENEX HFA               (M)    ...................................Tier 3
MAcrOlides                                                                    NIZORAL         [KETOCONAZOLE] ........................Tier               3   ZYFLO CR           (ST) (M) (QL) ..............................Tier       3
AZITHROMYCIN                 (Zithromax) (QL) ...............Tier         1   NYSTATIN .................................................Tier 1
BIAXIN       [CLARITHROMYCIN]...........................Tier              3   SPORANOX             [ITRACONAZOLE] (QL)(PA) .......Tier                  3
                                                                                                                                                            cArdiOVAscUlAr
BIAXIN XL          [CLARITHROMYCIN ER]             ...............Tier 3      TERBINAFINE              (Lamisil) (QL) ........................Tier      1   Ace inHiBitOrs
CLARITHROMYCIN (Biaxin) .......................Tier 1                         VFEND (QL) .................................................Tier 3            ACCUPRIL           [QUINAPRIL] (M)        ........................Tier 3
CLARITHROMYCIN ER                       (Biaxin XL)............Tier       1                                                                                 ACEON (M) ..................................................Tier 3
E.E.S. .............................................................Tier 1
                                                                              AntiVirAls                                                                    ALTACE [RAMIPRIL] (M) ................................Tier 3
                                                                              ACYCLOVIR            (Zovirax)    ..................................Tier 1    BENAZEPRIL             (Lotensin) (M) (GS)..................Tier          1
ERY-TAB ....................................................Tier 2
                                                                              FAMCICLOVIR              (Famvir) ...............................Tier     1   CAPOTEN          [CAPTOPRIL] (M) .........................Tier            3
ERYTHROMYCIN                  (Ery-Tab) .........................Tier     1
                                                                              FAMVIR        [FAMCICLOVIR]         ...............................Tier 3     CAPTOPRIL            (Capoten) (M)       ...........................Tier 1
ZITHROMAX              [AZITHROMYCIN] (QL)           ............Tier 3
                                                                              VALTREX ...................................................Tier 3             ENALAPRIL            (Vasotec) (M) (GS) .....................Tier         1
ZMAX       (QL) ...................................................Tier   3
                                                                              ZOVIRAX         [ACYCLOVIR] ................................Tier          3   FOSINOPRIL            (Monopril) (M) .........................Tier        1
Misc. AntiBiOtics                                                                                                                                           LISINOPRIL                                     ....................Tier 1
                                                                              AnxietY & sleep disOrder                                                                          (Prinivil/Zestril) (M)
ALINIA       (QL) .................................................Tier   3   ALPRAZOLAM                (Xanax) ...............................Tier     1   MAVIK      [TRANDOLAPRIL] (M) .........................Tier               3
BACTRIM          [SMZ-TMP]      ...................................Tier 3     ALPRAZOLAM ER                    (Xanax XR) (QL) ............Tier         1   PRINIVIL       [LISINOPRIL] (M) ............................Tier          3
CLINDAMYCIN               (Cleocin) .............................Tier     1   AMBIEN        [ZOLIPIDEM] (QL) (ST) .....................Tier             3   QUINAPRIL           (Accupril) (M) (GS) .....................Tier         1
KETEK ........................................................Tier 3          AMBIEN CR           (QL) (ST) .................................Tier       3   RAMIPRIL         (Altace) (M) ..................................Tier      1
MACROBID             [NITROFURANTOIN] ..................Tier              3   ATIVAN       [LORAZEPAM] ..................................Tier           3   TRANDOLAPRIL                  (Mavik) (M) ......................Tier      1
METRONIDAZOLE                     (Flagyl) ........................Tier   1   BUSPAR        [BUSPIRONE]         .................................Tier 3
                                                                                                                                                            AlpHA- 1 BlOcKers
NITROFURANTOIN                     (Macrobid) ..................Tier      1   BUSPIRONE (Buspar) ...................................Tier 1
                                                                                                                                                            DOXAZOSIN             (Cardura) (M) ...........................Tier       1
SMZ-TMP          (Bactrim/Septra)       ............................Tier 1    DIAZEPAM           (Valium) .....................................Tier     1
                                                                                                                                                            HYTRIN       [TERAZOSIN] (M) .............................Tier            3
XIFAXAN          (QL) .............................................Tier   3   EDLUAR         (QL) (ST)    .......................................Tier 3




RXSELECT PDL 01/01/10                                                                                                                                                                                                                 2
PRAZOSIN                  (Minipress) (M) ............................ Tier                       1   cArdiAc GlYcOsides                                                                                     VYTORIN
TERAZOSIN                    (Hytrin) (M) .............................. Tier                     1                                                                                                          10/20, 10/40, 10/80 mg (QL) (M)           ......................... Tier 2
                                                                                                      DIGOXIN               (Lanoxin) (M) .................................. Tier                        1
                                                                                                                                                                                                             WELCHOL            (M) ............................................ Tier   2
AnGiOtensin ii receptOr                                                                               LANOXIN                [DIGOXIN] (M) .............................. Tier                           2
                                                                                                                                                                                                             ZETIA     (QL) (M) ............................................. Tier      2
BlOcKers                                                                                              cOMBinAtiOns/OtHer                                                                                     ZOCOR        [SIMVASTATIN] (QL) (M) .................... Tier              3
ATACAND                 (ST) (M) (QL)............................... Tier                         3   AMLODIPINE/BENAZEPRIL
AVAPRO               (ST) (M) (QL)           ................................. Tier 3                 (Lotrel) (M) .............................................................................. Tier   1   cOntrAceptiOn
BENICAR                (ST) (M) (QL) ................................ Tier                        3   ATACAND HCT                         (ST) (M) (QL) ..................... Tier                       3   (BirtH cOntrOl)
                                                                                                      AVALIDE               (ST) (M) (QL) ................................. Tier                         3   APRI    (Desgen and Ortho-Cept) (M).................... Tier               1
COZAAR                (M) (QL) ........................................ Tier                      2
                                                                                                      BENAZEPRIL HCTZ                                                                                        CESIA     (Cyclessa) (M) ...................................... Tier       1
DIOVAN              (M) (QL) ......................................... Tier                       2
                                                                                                      (Lotensin HCT) (M) (QL) ...................................... Tier 1                                  CYCLESSA           [CESIA & VELIVET] (M)           ............... Tier 3
MICARDIS                 (ST) (M) (QL)          .............................. Tier 3
                                                                                                      BENICAR HCT                       (ST) (M) (QL)           ...................... Tier 3                DEMULEN           (M)............................................. Tier    3
TEVETEN                (ST) (M) (QL)................................ Tier                         3
                                                                                                      BISOPROLOL HCTZ                                (Ziac) (M) .................. Tier                  1   DESOGEN ................................................. Tier 3
AntiAdrenerGics                                                                                       CAPOZIDE                  [CAPTOPRIL/HCTZ] (M)                      .............. Tier 3              KARIVA        (Mircette) (M) ................................... Tier      1
ALDOMET                  [METHYLDOPA]                .......................... Tier 3
                                                                                                      CAPTOPRIL HCTZ                             (Capozide) (M) .............. Tier                      1   LEVORA         (Nordette) (M) ................................. Tier       1
CATAPRES                  [CLONIDINE] (M) ........................ Tier                           3
                                                                                                      DIOVAN HCT                      (M) (QL) ................................ Tier                     2   LOESTRIN FE (Microgestin) (M) ................... Tier 3
CATAPRES TTS                         (M)................................... Tier                  3
                                                                                                      ENALAPRIL HCTZ                             (Vaseretic) (M) .............. Tier                     1   LYBREL        (M) ................................................. Tier   3
CLONIDINE (Catapres) (M) ............................ Tier 1
                                                                                                      EXFORGE                  (M) (QL)...................................... Tier                       2   MICROGESTIN/FE                   (Loestrin) (M) ................ Tier      1
METHYLDOPA                         (Aldomet) (M) ...................... Tier                      1
                                                                                                      EXFORGE HCT                         (M) (QL) ............................ Tier                     2   MIRCETTE           [KARIVA] (M) .............................. Tier        3
BetA-BlOcKers                                                                                         FOSINOPRIL HCTZ                              (Monopril HCT) (M)                ...... Tier 1           NECON        (Ortho-Novum) (M)          ............................ Tier 1
ATENOLOL                   (Tenormin) (M) ........................... Tier                        1   HYZAAR                (M) (QL) ........................................ Tier                       2   NORTREL           (Ortho-Novum) (M) ........................ Tier          1
BETAPACE AF                       [SOTALOL/AF] (M)                 .............. Tier 3              LISINOPRIL HCTZ                            (Prinzide) (M) (GS) ......... Tier                      1   NUVARING            (QL) (M).................................... Tier      2
BISOPROLOL (Zebeta) (M)........................... Tier 1                                             LOTENSIN HCT                                                                                           OCELLA (Yasmin 28) (M) ................................ Tier 1
BYSTOLIC                 (QL) ........................................... Tier                    3   [BENAZEPRIL-HCTZ] (M) (QL)                          ........................... Tier 3                 ORTHO EVRA               (QL) (M) .............................. Tier      3
CARVEDILOL                      (Coreg)        ................................ Tier 1                LOTREL              [AMLODIPINE/BENAZEPRIL] (M)                             ....... Tier 3             ORTHO MICRONOR                      (M) .......................... Tier    3
COREG             (Carvedilol) (M) ................................. Tier                         3   MICARDIS HCT                        (ST) (M) (QL) ..................... Tier                       3   ORTHO TRI-CYCLEN LO                         (M)   ................. Tier 3
COREG CR                  (M) ........................................... Tier                    2   QUINARETIC                      (Accuretic) (M) ........................ Tier                      1   ORTHO-CEPT               (M)...................................... Tier    3
IMDUR            [ISOSORBIDE MONONITRATE] (M)                               ....... Tier 3            RANEXA (ST) (M) (QL) ................................. Tier 2                                          ORTHO-CYCLEN                   (M) ................................ Tier   3
INDERAL LA                    [PROPRANOLOL ER] (M) ......... Tier                                 3   TARKA             (M) ................................................... Tier                     2   ORTHO-NOVUM                  (M) ................................. Tier    3
INNOPRAN XL                        (M) .................................... Tier                  2   TEKTURNA                    (ST) (M) (QL) ............................ Tier                        3   OVCON         (M).................................................. Tier   3
ISORDIL             [ISOSORBIDE DINITRATE] (M)........... Tier                                    3   TEVETEN HCT                        (ST) (M) (QL) ...................... Tier                       3   PREVIFEM (Ortho-Cyclen) (M) ....................... Tier 1
ISOSORBIDE DINITRATE                                      (Isordil) (M) ...... Tier               1   TYVASO PR                    (M)    ......................................... Tier 3                   QUASENSE             (Seasonale) (QL) (M) ................... Tier         1
ISOSORBIDE MONONITRATE                                                                                VALTURNA (ST) (M) ..........................Tier 3                                                     SEASONALE              (QL) (M) ................................ Tier      3
(Imdur)(M) ............................................................................... Tier   1                                                                                                          SEASONIQUE [QUASENSE]                      (QL) (M) ........... Tier       3
                                                                                                      diUretics (WAter pills)
LABETALOL                     (Trandate) (M) .......................... Tier                      1   EPLERENONE [INSPRA]                                (ST) (M) ................. Tier                 1   SOLIA      (Desogen and Ortho-Cept) (M) ............... Tier               1
METOPROLOL SUCCINATE                                                                                  FUROSEMIDE                       (Lasix) (M) ............................ Tier                     1   SPRINTEC (Ortho-Cyclen) (M) ........................ Tier 1
(Toprol XL) (M) .................................................. Tier 1
                                                                                                      HYDROCHLOROTHIAZIDE                                                                                    TRINESSA          (Ortho Tri-Cyclen) (M)        ................... Tier 1
NITRO-DUR                    [NITROGLYCERIN] (M)                   .............. Tier 2              (HCTZ) (M) (GS) ................................................. Tier 1
                                                                                                                                                                                                             TRIPHASIL 28             (M)   ...................................... Tier 1
PROPRANOLOL                           (Inderal) (M) ..................... Tier                    1   INSPRA             [EPLERENONE] (ST) (M) ................... Tier                                  3   TRI-PREVIFEM (Ortho Tri-Cyclen) (M) ........... Tier 1
PROPRANOLOL ER                                (Inderal LA) (M) .......... Tier                    1   MAXZIDE                [TRIAMTERENE-HCTZ] (M) ............. Tier                                   3   VELIVET         (Cyclessa) (M) ................................. Tier      1
SOTALOL/AF                      (Betapace/AF) (M) .................. Tier                         1   SPIRONOLACTONE                                 (Aldactone) (M) .......... Tier                     1   YASMIN 28           [OCELLA] (M) ............................ Tier         3
TOPROL XL                                                                                             TRIAMTERENE-HCTZ (Maxzide) (M).......... Tier 1
[METOPROLOL SUCCINATE] (M).................................... Tier                               3                                                                                                          YAZ    (M)   ........................................................ Tier 2
                                                                                                      cHOlesterOl                                                                                            ZOVIA 1/50E (Demulen) (M) ......................... Tier 1
BlOOd MOdiFiers                                                                                       ADVICOR                 (QL) (M) (ST)           ............................... Tier 3
AGGRENOX                     (M) ......................................... Tier                   2                                                                                                          derMAtOlOGicAls (sKin)
                                                                                                      CADUET               (ST) (M) ......................................... Tier                       3
COUMADIN                    [WARFARIN] (M) ....................... Tier                           2                                                                                                          Acne
                                                                                                      CHOLESTYRAMINE                                (Questran) (M) ............ Tier                     1
EFFIENT              (QL) (M) ........................................ Tier                       3                                                                                                          ACCUTANE             [ISOTRETINOIN] ........................ Tier          3
                                                                                                      CRESTOR 10/20/40mg                                     (QL) (M) ............. Tier                 2
PLAVIX            (M) .................................................. Tier                     2                                                                                                          ACZONE .................................................... Tier 3
                                                                                                      CRESTOR 5mg                         (QL) (ST) (M)           ..................... Tier 2
WARFARIN                   (Coumadin) (M) .......................... Tier                         1                                                                                                          AMNESTEEM               (Accutane)     ............................. Tier 1
                                                                                                      FENOFIBRATE                        (Lofibra) (QL) (M) ................. Tier                       1
                                                                                                                                                                                                             AZELEX ..................................................... Tier 3
cAlciUM cHAnnel BlOcKers                                                                              GEMFIBROZIL                       (Lopid) (QL) (M)             ................... Tier 1
                                                                                                                                                                                                             BENZACLIN .............................................. Tier 2
AMLODIPINE                     (Norvasc) (M) (GS) .................. Tier                         1   LESCOL              (QL) (M) ......................................... Tier                        3
                                                                                                                                                                                                             BENZAMYCIN               [ERYTH/BP] ......................... Tier         3
CALAN             [VERAPAMIL] (M) .............................. Tier                             3   LIPITOR             (QL) (ST) (M)................................... Tier                          3
                                                                                                                                                                                                             BENZOYL PEROXIDE                      (Benzac) ................. Tier      1
CARDIZEM CD/LA                              [DILTIAZEM] (M) .......... Tier                       3   LOVASTATIN (Mevacor) (QL) (M) (GS)............ Tier 1
                                                                                                                                                                                                             BREVOXYL            (QL) ......................................... Tier    3
DILTIAZEM                  (Tiazac) (M) ................................ Tier                     1   NIASPAN                (QL) (M) ....................................... Tier                       2
                                                                                                                                                                                                             CLARAVIS (Accutane) ................................... Tier 1
DILTIAZEM ER                       (Cardizem CD) (M).................. Tier                       1   PRAVACHOL                      [PRAVASTATIN] (QL) (M) ......... Tier                               3
                                                                                                                                                                                                             DIFFERIN         (age limit)    ................................... Tier 2
NICARDIPINE                      (Cardene) (M) ........................ Tier                      1   PRAVASTATIN                       (Pravachol) (QL) (M) (GS) ....... Tier                           1
                                                                                                                                                                                                             DUAC /CS................................................... Tier 2
NIFEDIPINE                  (Adalat and Procardia) (M) .......... Tier                            1   QUESTRAN                    [CHOLESTYRAMINE] (M)                        ........... Tier 3
                                                                                                                                                                                                             EPIDUO        (age limit) ....................................... Tier     3
NIFEDIPINE ER                       (Procardia XL) (M) ............... Tier                       1   SIMCOR              (ST) (QL) ........................................ Tier                        3
                                                                                                                                                                                                             ERYTH-BP           (Benzamycin) ............................... Tier       1
NORVASC                  [AMLODIPINE] (M) ....................... Tier                            3   SIMVASTATIN                      (Zocor) (QL) (M) (GS) ............. Tier                          1
                                                                                                                                                                                                             ERYTHROMYCIN ....................................... Tier 1
VERAPAMIL                    (Calan/Verelan/Isoptin) (M) ........ Tier                            1   TRICOR             (QL) (M) .......................................... Tier                        3
                                                                                                                                                                                                             ISOTRETINOIN               (Accutane) .......................... Tier      1
VERELAN                 [VERAPAMIL] (M) ......................... Tier                            3   VYTORIN 10/10 mg                              (QL) (ST) (M) ............. Tier                     2
                                                                                                                                                                                                             METROCREAM                 [METRONIDAZOLE] ............ Tier               3



RXSELECT PDL 01/01/10                                                                                                                                                                                                                                                                   3
METROGEL ...............................................Tier 3                                        LEVEMIR          (M) ...............................................Tier   2   Ulcer treAtMents
METROLOTION                          [METRONIDAZOLE]............Tier                              2   NOVOLIN ..................................................Tier 2               ACIPHEX          (QL) (ST) (M)      ................................Tier 2
METRONIDAZOLE                               (Metrolotion)          ................Tier 1             NOVOLOG             (M) ............................................Tier   2   CIMETIDINE             (Tagamet) (M) ...........................Tier       1
RETIN-A              (age limit) [TRETINOIN] ...................Tier                              3   PRECISION TEST STRIPS                         (QL) (M) .........Tier       2   FAMOTIDINE (Pepcid) (QL) (M) ..................... Free
RETIN-A MICRO                          (age limit)........................Tier                    2   SYMLIN        (QL) (ST) (M) ...................................Tier        2   HYOSCYAMINE                 (Levsin) (M) ........................Tier      1
SOTRET              (Accutane) .......................................Tier                        1   SYMLIN PEN              (QL) (ST) (M) ..........................Tier       2   KAPIDEX          (ST) (QL) ......................................Tier      3
TRETINOIN                   (age limit) (Retin-A) ....................Tier                        1                                                                                  NEXIUM         (QL) (ST)(M) ...................................Tier        3
                                                                                                      OrAl AntidiABetics
ZIANA (age limit) ..........................................Tier 3                                                                                                                   OMEPRAZOLE                 (Prilosec) (QL) (M) (GS) ........Tier           1
                                                                                                      ACARBOSE             (Precose) (M) ............................Tier        1
AntiFUnGAls                                                                                           ACTOPLUS MET                   (M) .................................Tier   2   PANTOPRAZOLE                    (Protonix) (QL) (ST) (M) ...Tier           1

CICLOPIROX                     (Loprox/Penlac) .......................Tier                        1   ACTOS        (QL) (M)    ...........................................Tier 2     PREVACID           (QL) (ST) (M) ..............................Tier        2

CLOTRIMAZOLE........................................Tier 1                                            AMARYL          [GLIMEPIRIDE] (M)         .........................Tier 3      PREVPAC           (QL) (M) ......................................Tier      2

CLOTRIMAZOLE-BETAMETH                                                                                 AVANDAMET               (M) .......................................Tier    2   PRILOSEC          [OMEPRAZOLE] (QL) (ST) (M) .......Tier                   3
(Lotrisone) .............................................................................. Tier   1   AVANDARYL               (M)   .......................................Tier 2    PROTONIX           [PANTOPRAZOLE] (QL) (ST) (M) ..Tier                     3
KETOCONAZOLE                              (Nizoral) ........................Tier                  1   AVANDIA           (M) (QL) .......................................Tier     2   PYLERA         (M) ................................................Tier    3
PENLAC               (Ciclopirox) (QL) .............................Tier                          3   DUETACT           (M)   .............................................Tier 2    RANITIDINE HCL                 (Zantac) (QL) (M)       ............. Free

                                                                                                      GLIMEPIRIDE                               ..........................Tier 1     ZANTAC         [RANITIDINE] (QL) (M) ....................Tier              3
AntipsOriAtics                                                                                                                 (Amaryl) (M)

                                                                                                      GLIPIZIDE          (Glucotrol) (M)..............................Tier       1   ZEGERID          (QL) (ST) (M)      ................................Tier 3
DOVONEX .................................................Tier 2
SORIATANE ..............................................Tier 2                                        GLIPIZIDE XL             (Glucotrol XL) (M) ...................Tier        1   HOrMOne replAceMent
TAZORAC ...................................................Tier 2                                     GLIPIZIDE-MET                 (Metaglip) ..........................Tier    1   tHerApY
VECTICAL ..................................................Tier 3                                     GLUCOPHAGE                 [METFORMIN] (M) ...............Tier             3   FeMAle
                                                                                                      GLUCOPHAGE XR                     [METFORMIN] (M) ........Tier             3   ACTIVELLA             (M) ..........................................Tier   2
Misc. derMAtOlOGicAls
                                                                                                      GLUCOTROL               [GLIPIZIDE] (M) ......................Tier         3   CENESTIN           (M) ............................................Tier    2
ALDARA .....................................................Tier 2
                                                                                                      GLUCOTROL XL                   [GLIPIZIDE ER] (M) ...........Tier          3   CLIMARA          [ESTRADIOL] (M) ..........................Tier            2
ALTABAX....................................................Tier 3
                                                                                                      GLUCOVANCE                 [GLYBURIDE/MET] (M) .........Tier               3   CRINONE          (minimum age)         .............................Tier 3
BACTROBAN                       [MUPIROCIN] ........................Tier                          2
                                                                                                      GLYBURIDE             (Diabeta/Micronase) (M) .............Tier            1   ENJUVIA (M) ...............................................Tier 2
CARAC .......................................................Tier 2
                                                                                                      GLYBURIDE/MET (Glucovance) (M) .............Tier 1                             ESTRADERM               (M) .......................................Tier    2
EFUDEX               [FLUOROURACIL] ...........................Tier                               3
                                                                                                      JANUMET            (QL) (M) ......................................Tier     2   ESTRADIOL              (Estrace) (M) .............................Tier     1
ELIDEL            (ST) .................................................Tier                      2
                                                                                                      JANUVIA (QL) (M) .......................................Tier 2                 ESTRADIOL PATCH                     (Climara) (M) ..............Tier       1
FLUOROURACIL (Efudex) ..........................Tier 1
                                                                                                      METAGLIP           [GLIPIZIDE-METFORMIN] (M) ........... Tier              3   ESTRATEST              [SYNTEST] (M) .........................Tier         2
MUPIROCIN                    (Bactroban) ..............................Tier                       1
                                                                                                      METFORMIN               (Glucophage) (M) (GS) ..............Tier           1   ESTRING ....................................................Tier 2
ORACEA                (ST) ..............................................Tier                     3
                                                                                                      METFORMIN ER                                                                   ESTROGEL            (M) ...........................................Tier    2
PROTOPIC                  (ST) ...........................................Tier                    2   (Glucophage XR) (M) (GS) ...................................Tier           1
REGRANEX                    (QL)      .......................................Tier 3                                                                                                  ESTROPIPATE               (Ogen) (M) ...........................Tier       1
                                                                                                      ONGLYZA            (QL) (M)     .....................................Tier 3
                                                                                                                                                                                     FEMHRT         (M) ................................................Tier    3
sterOids                                                                                              PRANDIN           (M) ..............................................Tier   2
                                                                                                                                                                                     FEMTRACE              (M) ..........................................Tier   3
BETAMETHASONE                                (Diprolene) ..................Tier                   1   PRECOSE           [ACARBOSE] (M)          .........................Tier 3
                                                                                                                                                                                     MEDROXYPROGESTERONE
CLOBETASOL (Temovate) ............................Tier 1                                                                                                                             (Provera) (M) .....................................................Tier 1
                                                                                                      GAstrOintestinAl
DERMATOP [PREDNICARBATE] ....................Tier 3                                                                                                                                  NORETHINDRONE                     (Aygestin) (M) ..............Tier        1
                                                                                                      (diGestiVe)
DESONIDE                  (Desowen) ..................................Tier                        1                                                                                  PREMARIN            (M) ...........................................Tier    2
                                                                                                      Misc. GAstrOintestinAl
ELOCON                [MOMETASONE] .............................Tier                              3                                                                                  PREMPHASE               (M)........................................Tier    2
                                                                                                      AMITIZA         (QL) ..............................................Tier    2
HYDROCORTISONE                                 (Hytone) ...................Tier                   1                                                                                  PREMPRO           (M)    ............................................Tier 2
                                                                                                      ASACOL          (M) ................................................Tier   2
KENALOG                  [TRIAMCINOLONE] ......................Tier                               3                                                                                  PROGESTERONE                    (PA)   .............................Tier 3
                                                                                                      DIPHENOXYLATE-ATROPINE
LIDEX          [FLUOCINONIDE]                 ................................Tier 3                  (Lomotil) ...........................................................Tier 1    PROMETRIUM                (minimum age) (M) ...............Tier            2
MOMETASONE                          (Elocon)       .............................Tier 1                ENTOCORT EC .........................................Tier 3                    PROVERA           [MEDROXYPROGESTERONE] (M) ...Tier                        3
OLUX ...........................................................Tier 3                                LIALDA (QL) (M)...........................................Tier 2               SYNTEST          (Estratest)    .....................................Tier 1
PREDNICARBATE                             (Dermatop)           ...................Tier 1              LOTRONEX             (QL) (PA) (M) ............................Tier        3   VAGIFEM          (M)   ..............................................Tier 2
TEMOVATE                   [CLOBETASOL]..........................Tier                             3   METOCLOPRAMIDE HCL                           (Reglan) (M) .....Tier        1   VIVELLE         (M)   ...............................................Tier 2
TRIAMCINOLONE ACETONIDE                                                                               RENVELA           (M) .............................................Tier    2   VIVELLE-DOT               (M) .....................................Tier    2
(Kenalog) ..........................................................Tier 1
                                                                                                      PENTASA           (M)..............................................Tier    2
WESTCORT                    [HYDROCORTISONE] ................Tier                                 3                                                                                  MAle
                                                                                                      nAUseA & VOMitinG                                                              ANDRODERM                 (ST) (M) ...............................Tier     2
diABetic                                                                                              ANZEMET            (QL) ...........................................Tier    3   ANDROGEL               (M) .........................................Tier   2
inJectABle And OtHer                                                                                  EMEND         (QL) ................................................Tier    3   TESTIM        (ST) (M) ...........................................Tier     3
APIDRA              (M) .................................................Tier                     3   GRANISETRON (QL) (Kytril) ........................Tier 1                       STRIANT         (ST) (M) ........................................Tier      3
BYETTA              (QL) (ST) (M)...................................Tier                          2   KYTRIL        [GRANISETRON] (QL) ........................Tier              3
FREESTYLE TEST STRIPS                                        (QL) (M)       .......Tier 2
                                                                                                                                                                                     iMMUnOsUppressAnts
                                                                                                      ONDANSETRON (Zofran) (QL) ....................Tier 1                           AZATHIOPRINE                 (Imuran) (M) ......................Tier       1
GLUCAGON ...............................................Tier 2                                        ONDANSETRON ODT (Zofran ODT) (QL) ... Tier 1                                   CELLCEPT           [MYCOPHENOLATE] (M) ..............Tier                  2
HUMALOG                   (PA) (M)       ....................................Tier 3                   PHENERGAN               [PROMETHAZINE] ..................Tier              3   CYCLOSPORINE
HUMALOG 50/50 and 75/25                                            (M)    .........Tier 2             PROMETHAZINE (Phenergan) .....................Tier 1                           (Sandimmune and Neoral) (M)..............................Tier              1
HUMULIN                (PA) (M).......................................Tier                        3   ZOFRAN          [ONDANSETRON] (QL)              ...................Tier 3      GENGRAF            (Neoral) (M) .................................Tier      1
LANTUS               (M) ................................................Tier                     2   ZOFRAN ODT                [ONDANSETRON ODT] (QL)...Tier                    3   IMURAN         [AZATHIOPRINE] (M) .......................Tier              3




RXSELECT PDL 01/01/10                                                                                                                                                                                                                                           4
MYCOPHENOLATE                    (Cellcept) (M) .............. Tier       1   PAXIL       [PAROXETINE] (QL) (ST) (M) ................. Tier               3   SOMA 250 mg (PA) ................................... Tier 3
MYFORTIC          (M) ........................................... Tier    3   PAXIL CR          (QL) (ST) (M) ................................ Tier       3   TIZANIDINE (Zanaflex) ................................. Tier 1
NEORAL        (Cyclosporin) (M) ............................ Tier         2   PEXEVA          (QL) (ST) (M) .................................. Tier       3
                                                                                                                                                              ZANAFLEX [TIZANIDINE] ............................ Tier 3
PROGRAF          (M)   ............................................ Tier 2    PRISTIQ (QL) (ST) (M) ................................... Tier 2
RAPAMUNE            (M) ......................................... Tier    2   PROZAC          [FLUOXETINE] (QL) (ST) (M) ............ Tier                3   OncOlOGics/HeMAtOlOGY
                                                                                                                                                              AFINITOR          (QL) (PA)    .................................... Tier 2
SANDIMMUNE               [CYCLOSPORINE] (M)            .......... Tier 2      RAPIFLUX            [FLUOXETINE] (ST)         ..................... Tier 3
                                                                                                                                                              ARIMIDEX          (QL) (M) ..................................... Tier      2
                                                                              REMERON             [MIRTAZAPINE] (ST) (M) (QL) ....... Tier                3
MentAl HeAltH                                                                                                                                                 AROMASIN            (QL) (M) ................................... Tier      2
                                                                              SARAFEM            (ST) (M) ...................................... Tier     3
AdHd/stiMUlAnts (AttentiOn                                                                                                                                    CHROMAGEN               (PA) .................................... Tier     3
                                                                              SERTRALINE (Zoloft) (QL) (M) (GS) .............. Tier 1
deFicit & HYperActiVitY)                                                                                                                                      GLEEVEC ................................................... Tier 2
                                                                              TRAZODONE                (Desyrel) (M) .......................... Tier      1
ADDERALL           [AMPHETAMINE SALTS] ............. Tier                 3                                                                                   HYCAMTIN            (QL)   ......................................... Tier 2
                                                                              VENLAFAXINE (Effexor) (M) ........................ Tier 1
ADDERALL XR               (QL) .................................. Tier    3                                                                                   IRESSA       (PA)................................................. Tier    2
                                                                              VENLAFAXINE ER (QL) ............................ Tier 3
AMPHETAMINE SALT                     (Adderall) ............... Tier      1                                                                                   NEXAVAR           (PA)............................................ Tier    2
                                                                              WELLBUTRIN                [BUPROPION] (QL) (ST) (M)... Tier                 3
AMPHETAMINE SALT ER                        (QL) ............... Tier      3                                                                                   PROMACTA             (PA) ........................................ Tier    2
                                                                              WELLBUTRIN SR
CONCERTA           (QL) ........................................ Tier     2                                                                                   REVLIMID          (QL) (PA) .................................... Tier      2
                                                                              [BUPROPION SR](QL)(ST)(M) ............................. Tier                3
DAYTRANA (QL) ........................................ Tier 3                                                                                                 SPRYCEL          (QL) (PA)...................................... Tier      2
                                                                              WELLBUTRIN XL
DEXEDRINE           [DEXTROAM] (QL) ................... Tier              3   [BUPROPRION XL](QL)(ST)(M) ........................... Tier                 3   SUTENT         (PA) ............................................... Tier   2
DEXEDRINE CR               [DEXTROAM SR] (QL) ........ Tier               3   ZOLOFT          [SERTRALINE] (QL) (ST) (M)             ............ Tier 3      TAMOXIFEN (M) .......................................... Tier 1
DEXTROAM            (Dexedrine) (QL)       ....................... Tier 1                                                                                     TARCEVA          (PA) ............................................ Tier    2
                                                                              AntipsYcHOtics
DEXTROAM SR                (Dexedrine CR) (QL) ............ Tier          1                                                                                   TARGRETIN            (QL) ........................................ Tier    2
                                                                              ABILIFY         (QL) (M) ......................................... Tier     2
FOCALIN XR             (QL) ...................................... Tier   3                                                                                   TASIGNA (PA) ............................................. Tier 2
                                                                              CLOZAPINE (Clozaril) (M) ............................. Tier 1
METADATE CD ........................................ Tier 3                                                                                                   TYKERB         (QL) (PA)    ....................................... Tier 2
                                                                              GEODON            (QL) (M) ....................................... Tier     2
METADATE ER               [METHYLIN ER] ................... Tier          3                                                                                   XELODA .................................................... Tier 2
                                                                              HALOPERIDOL                 (M) .................................... Tier   1
METHYLIN ................................................. Tier 3                                                                                             ZOLINZA          (QL) (PA)...................................... Tier      2
                                                                              INVEGA         (QL) (PA) (M) .................................. Tier        3
METHYLPHENIDATE                     (Ritalin)   ................... Tier 1
                                                                              RISPERDAL             [RISPERIDONE] (QL) (M) ........... Tier               3   OpHtHAlMics (eYe)
MYCOPHENOLATE                    (Cellcept) (M) .............. Tier       1
                                                                              RISPERDONE               (Risperdal) (QL) (M) ............... Tier          1   Anti-inFectiVes
NUVIGIL       (QL) (PA) ....................................... Tier      3
                                                                              SAPHRIS          (ST) (M)    ....................................... Tier 3     CILOXAN          [CIPROFLOXACIN] ......................... Tier            3
PROVIGIL        (QL) (PA)..................................... Tier       3
                                                                              SEROQUEL, XR                 (QL) (M) ........................... Tier      2   CIPROFLOXACIN (CIPRO) .......................... Tier 1
RITALIN      [METHYLPHENIDATE] ....................... Tier               3
                                                                              SYMBYAX            (M) ............................................. Tier   3   GENTAMICIN ............................................. Tier 1
RITALIN LA         (QL)    ........................................ Tier 3
                                                                              ZYPREXA            (QL) (M) ...................................... Tier     2   OCUFLOX           [OFLOXACIN] .............................. Tier          2
RITALIN SR         [METHYLPHENIDATE] (QL) ......... Tier                  3
                                                                              MiGrAine                                                                        OFLOXACIN             (Ocuflox) ................................. Tier     1
STRATTERA            (QL) ....................................... Tier    3
                                                                              AMERGE           (QL)   ............................................. Tier 2    TOBRAMYCIN ............................................ Tier 1
VYVANSE         (QL) ............................................ Tier    2
                                                                              APAP W/ BUTALBITAL (Phrenilin) (QL)..... Tier 1                                 VIGAMOX .................................................. Tier 3
XYREM       (PA) ................................................. Tier   3
                                                                              AXERT        (QL) ................................................. Tier    3   ZYMAR ....................................................... Tier 3
AlZHeiMers                                                                    BUTALBITAL-APAP-CAFFEINE                                                        ALOCRIL (M) ............................................... Tier 2
ARICEPT (M) ............................................... Tier 2            (Esgic) .............................................................. Tier 1
                                                                                                                                                              CROMOLYN (Crolom) ................................... Tier 1
EXELON        (M) ................................................ Tier   3   BUTALBITAL-ASA-CAFFEINE
GALANTAMINE                (Razadyne) (M) ................... Tier        1   (Fiorinal) ........................................................... Tier 1   Misc. OpHtHAlMics
GALANTAMINE ER                   (Razadyne ER) (M)        ....... Tier 1      CAFERGOT              [ERGOTAMINE/CAFF.]            ............... Tier 3      ALOCRIL (M) ............................................... Tier 2
NAMENDA           (M)   ........................................... Tier 2    FIORICET          [BUTALBITAL/APAP/CAFF.]............ Tier                  3   COSOPT          [DORZOLAMIDE-TIMOLOL] (M)                ........ Tier 3
RAZADYNE           [GALANTAMINE] (M) ................. Tier               3   FROVA         (QL) ................................................. Tier   3   CROMOLYN (Crolom) ................................... Tier 1
RAZADYNE ER               [GALANTAMINE ER] (M) ...... Tier                3   IMITREX         [SUMATRIPTAN] (QL)....................... Tier              3   DORZOLAMIDE                 (Trusopt) (M) ..................... Tier       1
                                                                              MAXALT/ MLT               (QL)   ................................... Tier 2     DORZOLAMIDE-TIMOLOL
AntidepressAnts                                                                                                                                               (Cosopt) (M) ..................................................... Tier 1
                                                                              RELPAX          (QL) ............................................... Tier   3
AMITRIPTYLINE (Elavil) (M) ........................ Tier 1
                                                                                                                                                              ELESTAT .................................................... Tier 2
                                                                              SUMATRIPTAN                 (Imitrex) (QL) ...................... Tier      1
APLENZIN         (QL) (ST)     ................................... Tier 3
                                                                                                                                                              OPTIVAR .................................................... Tier 2
                                                                              TREXIMET (QL) .......................................... Tier 3
BUPROPION,SR,XL
                                                                                                                                                              PATADAY (M) .............................................. Tier 3
(Wellbutrin,SR,XL)(QL)(M)(GS)          ............................ Tier 1    ZOMIG        (QL).................................................. Tier    3
                                                                                                                                                              PATANOL ................................................... Tier 2
CELEXA        [CITALOPRAM] (QL) (ST) (M) ............ Tier                3   ZOMIG ZMT             (QL) ........................................ Tier    3
                                                                                                                                                              RESTASIS ................................................... Tier 3
CITALOPRAM              (Celexa) (QL) (M) (GS) ............ Tier          1
CYMBALTA           (ST) (M) (QL) ............................ Tier        2   MUscle relAxAnts                                                                TIMOLOL (Timoptic) (M) ................................ Tier 1
                                                                              AMRIX® (QL) (PA) ......................................... Tier 3               TRUSOPT [DORZOLAMIDE] (M) ..................... Tier 3
DESYREL         [TRAZODONE] (M) ........................ Tier             3
                                                                              BACLOFEN ................................................ Tier 1
EFFEXOR         [VENLAFAXINE] (ST) (M) ............... Tier               3                                                                                   prOstAGlAndins
                                                                              CARISOPRODOL CMP/CODEINE ....... Tier 1
EFFEXOR XR              (QL) (ST) (M)......................... Tier       2                                                                                   COMBIGAN (M) (QL) ................................... Tier 2
                                                                              CARISOPRODOL/ CMP
EMSAM       (QL) (ST) (M).................................... Tier        3             ............................................. Tier 1
                                                                              (Soma/ CMP) (QL)                                                                LUMIGAN (M) .............................................. Tier 2
FLUOXETINE             (Prozac) (M) (GS) .................... Tier        1   CYCLOBENZAPRINE (Flexeril) .................. Tier 1                            XALATAN (M) .............................................. Tier 2
IMIPRAMINE           (Tofranil) (M) ............................ Tier     1   FLEXERIL                                   ........................ Tier 3
                                                                                                 (Cyclobenzaprine)
                                                                                                                                                              OsteOpOrOsis treAtMents
LEXAPRO         (QL) (ST)     .................................... Tier 3     METHOCARBAMOL                       (Robaxin)     .................. Tier 1     ACTONEL (QL) (M) (ST) ............................... Tier 2
MIRTAZAPINE              (Remeron) (QL) (M) ............... Tier          1   ROBAXIN           [METHOCARBAMOL]..................... Tier                 3   ALENDRONATE                  (Fosamax) (QL) (M) (GS) .... Tier             1
NORTRIPTYLINE                (Pamelor) (M) .................. Tier        1   SKELAXIN ................................................. Tier 3               BONIVA (QL) (M) (PA) ................................... Tier 3
PAMELOR          [NORTRIPTYLINE] (M) .................. Tier              3   SOMA /CMP               [CARISOPRODO/ CMP] (QL) ..... Tier                  3   EVISTA (QL) (M) ........................................... Tier 2
PAROXETINE (Paxil) (QL) (M) (GS) ............... Tier 1


RXSELECT PDL 01/01/10                                                                                                                                                                                                                    5
FOSAMAX (Alendronate) (QL) (M) (ST) ..........Tier 3                            PREVACID NAPRAPAC (M) .....................Tier 2                            CYTOMEL (M) .............................................Tier 2
FOSAMAX D              (Alendronate) (QL) (M) (ST) ......Tier               2                                                                                LEVOTHROID (M) ......................................Tier 2
                                                                                prenAtAl VitAMins
MIACALCIN [CALCITONIN] (M) .....................Tier 2                          Prenatal Vitamins- Brand (M) ................Tier 3                          LEVOXL        (M) ................................................Tier   2
                                                                                Prenatal Vitamins- Generic (M) ..............Tier 1                          SYNTHROID (M) ..........................................Tier 1
Otic prepArAtiOns (eAr)
CIPRO HC ..................................................Tier 2                                                                                            UNITHROID           (M) ..........................................Tier   2
                                                                                prOstAte
CIPRODEX .................................................Tier 2                AVODART (M) .............................................Tier 3              UrinArY incOntinence
FLOXIN [OFLOXACIN] ...................................Tier 3                    CARDURA            [DOXAZOSIN] (M) .......................Tier           3   DDAVP [DESMOPRESSIN] (PA) .......................Tier 3
                                                                                DOXAZOSIN (Cardura) (M) (GS) ....................Tier 1                      DESMOPRESSIN                (DDAVP) (PA) ...................Tier         1
OFLOXACIN              (Floxin) ....................................Tier    1
                                                                                FINASTERIDE              (Proscar) (ST) (M) ..................Tier       1   DETROL (M) ................................................Tier 3
pAin MedicAtiOns                                                                                                                                             DETROL LA           (M) .........................................Tier    3
                                                                                FLOMAX (M) ................................................Tier 2
nArcOtic AnAlGesics                                                             PRAZOSIN (Minipress) (M).............................Tier 1                  DITROPAN [OXYBUTIN] (M) .........................Tier 3
ACTIQ [FENTANYL] (QL) (PA) .........................Tier 3                                                                                                   DITROPAN XL [OXYBUTININ ER] (M) ...........Tier 3
                                                                                PROSCAR [FINASTERIDE] (ST) (M) ................Tier 3
AVINZA (QL) ................................................Tier 2                                                                                           ENABLEX (M) ..............................................Tier 3
                                                                                TERAZOSIN (Hytrin) (M)...............................Tier 1
BUTALBITAL                                                                                                                                                   HYOSCYAMINE               (Cystospaz) (M)      ..................Tier 1
                                                                                UROXATRAL (M) ........................................Tier 3
CAFF-APAP-cod(Fioricet w/ Cod)(QL) ..................Tier                   1
                                                                                                                                                             MINIRIN (PA).................................................Tier 1
BUTORPHANOL (Stadol) (QL).....................Tier 1                            seiZUre disOrder                                                             OXYBUTYNIN ER (Ditropan) (M) .................Tier 1
DURAGESIC [FENTANYL] (QL) .....................Tier 3                           SABRIL PR           (QL) (M) ....................................Tier    3
                                                                                                                                                             OXYTROL (M) .............................................Tier 3
EMBEDA PR ....................................... Tier 3                        BANZEL (M) ................................................Tier 3
                                                                                                                                                             STIMATE .....................................................Tier 3
FENTANYL             (Actiq) (QL) (PA)      ........................Tier 1      CARBAMAZEPINE (Tegretol) (M)................Tier 1
                                                                                                                                                             TOVIAZ (M) ..................................................Tier 3
FENTANYL             (Duragesic) (QL) .........................Tier         1   CARBATROL (M) ........................................Tier 2
                                                                                                                                                             VESICARE (M).............................................Tier 3
FENTORA            (QL) (PA) ....................................Tier       3   CLONAZEPAM                (Klonopin) (M)      .....................Tier 1

HYDROCODONE                                                                     DEPAKOTE [DIVALPROEX] (M) (QL) ..............Tier 3                          UncAteGOriZed
W/APAP (Lortab/Vicodin) (QL) ....................................... Tier   1   DILANTIN          [PHENYTOIN] (M) .........................Tier          2   ADCIRCA         (PA) ............................................Tier    3
KADIAN (QL) ...............................................Tier 2               DIVALPROEX              [DEPAKOTE] (M) ....................Tier          1   KUVAN (PA) .................................................Tier 3
LORCET [HYDROCODONE-APAP] (QL) ...........Tier 3                                GABAPENTIN               (Neurontin) (QL) (M) ..............Tier         1   LETAIRIS (PA) ..............................................Tier 3
LORTAB [HYDROCODONE/APAP] (QL) ...........Tier 3                                GABITRIL (QL) (M) .......................................Tier 2              REVATIO (PA) ..............................................Tier 3
MORPHINE SULFATE (MS Contin) .............Tier 1                                KEPPRA [LEVETIRACETAM] (QL) (M) ..............Tier 3                         TRACLEER (PA) ..........................................Tier 3
MS CONTIN [MORPHINE SULFATE] (QL) ........Tier 3                                KEPPRA XR (QL) (M) ..................................Tier 3                  ULORIC (ST)(QL) ..........................................Tier 3
NUCYNTA (QL) (PA) ....................................Tier 3                    LAMICTAL/ODT                                                                 XENAZINE          (PA) (QL) ...................................Tier      2
                                                                                [LAMOTRIGINE/ODT] (QL) (M) ...................................... Tier   3                                                                            ]
OPANA ER (QL) (PA) ...................................Tier 3
OXYCODONE-APAP                      (Percocet) (QL)      .........Tier 1        LAMICTAL XR (QL) (M) .......................................... Tier 3

OXYCODONE-ASPIRIN                        (Percodan) (QL)       ...Tier 1        LAMOTRIGINE (Lamictal) (QL) (M) ...............Tier 1

OXYCONTIN (QL) (ST) ................................Tier 3                      LEVETIRACETAM                  (Keppra) (QL) (M) ...........Tier         1

PERCOCET [OXYCODONE/APAP] (QL) ..........Tier 3                                 LYRICA (QL) (M) ...........................................Tier 3

PROPOXYPHENE                    (Darvon) (QL) .................Tier         1   NEURONTIN [GABAPENTIN] (QL) (M) ...........Tier 3

PROPOXYPHENE-APAP                                                               OXCARBAZEPINE                   (Trileptal) (QL) (M) .........Tier       1
        .................................................Tier 1
(Darvocet) (QL)                                                                 PHENYTOIN             (Dilantin) (M) ............................Tier    1
TRAMADOL (Ultram) (QL) ............................Tier 1                       TEGRETOL [CARBAMAZEPINE] (M) ...............Tier 2
TRAMADOL-APAP (Ultracet) (QL) ..............Tier 1                              TOPAMAX [TOPIRAMATE] (QL) (M) ...............Tier 3
ULTRACET [TRAMADOL/APAP] (QL) .............Tier 3                               TOPIRAMATE (Topamax)                   (QL) (M) ................Tier     1
ULTRAM [TRAMADOL/APAP] (QL) .................Tier 3                             TRILEPTAL [OXCARBAZEPINE] (QL) (M) ........Tier 3
ULTRAM ER (QL) ........................................Tier 3                   VIMPAT        (QL) (M) ..........................................Tier    2
VICODIN [HYDROCODONE-APAP] (QL) ..........Tier 3                                ZONEGRAN [ZONISAMIDE] (QL) (M).............Tier 3
VICOPROFEN [HYDROCODONE-IBU] (QL) ..Tier 3                                      ZONISAMIDE              (Zonegran) (QL) (M) ................Tier         1

nOn-sterOidAl Anti-                                                             sMOKinG cessAtiOn
inFlAMMAtOries                                                                  BUPROPION HCL                  (Zyban) (QL) ..................Tier       1
ARTHROTEC (M) ........................................Tier 3                    CHANTIX (QL) .............................................Tier 2
CELEBREX (QL) (M) ....................................Tier 3                    ZYBAN [BUPROPION] (QL) ............................Tier 2
DAYPRO [OXAPROZIN] (M) ...........................Tier 3
                                                                                sterOids
DICLOFENAC               (Voltaren) (M) (GS) .................Tier          1   HYDROCORTISONE                      (Cortef) (M) ...............Tier     1
FELDENE [PIROXICAM] (M) ..........................Tier 3                        MEDROL [METHYLPREDNISOLONE] ...............Tier 3
IBUPROFEN              (Motrin) (M) (GS) ....................     Tier 1        METHYLPREDNISOLONE (Medrol) ..........Tier 1
INDOMETHACIN (Indocin) (M) ....................Tier 1                           ORAPRED
KETOROLAC (Toradol) (QL) .........................Tier 1                        [PREDNISOLONE SOD PHOSPHATE]                  ...................Tier 3
MELOXICAM              (Mobic) (M) .............................Tier        1   PREDNISOLONE                  (Prelone) .........................Tier    1
MOBIC [MELOXICAM] (M) ...............................Tier 3                     PREDNISOLONE SOD PHOS
                                                                                (Orapred) ..........................................................Tier 1
MOTRIN [IBUPROFEN] (M) ............................Tier 3
                                                                                PREDNISONE (Sterapred) (M) ......................Tier 1
NABUMETONE (Relafen) (M) .......................Tier 1
                                                                                PRELONE           [PREDNISOLONE] (M) ...................Tier             3
NAPROXEN (Naprosyn) (M) (GS) ...................Tier 1
OXAPROZIN              (Daypro) (M) ............................Tier        1   tHYrOid
PIROXICAM             (Feldene) (M) ............................Tier        1   ARMOUR THYROID [THYROID] (M)...........Tier 3



RXSELECT PDL 01/01/10                                                                                                                                                                                                                 6
appendix B
benefit riders
Mental HealtH/CHeMiCal                                           m. Rest cures;
DepenDenCy Benefit RiDeR                                          n. Self-care or self-help training (nonmedical);
1. your Mental Health Benefits.
                                                                  o. Sensitivity training;
 This Benefit Rider provides mental health and chemical
 dependency Benefits for the treatment of emotional               p. Surgical procedures to remedy a condition
                                                                     diagnosed as psychological, emotional,
 conditions or chemical dependency listed as a mental
                                                                     or mental, including but not limited to
 disorder in the Diagnostic and Statistical Manual, as               transsexual or sex change treatment; and
 periodically revised, and which require professional
 intervention for as long as Services are considered              q. Neuropsychological testing for any
                                                                     of the following reasons:
 Medically Necessary. These Benefits are subject to
 all the provisions, limitations, and exclusions of your            i. Autism spectrum disorder/pervasive
 medical Benefits that are listed in the Certificate.                  developmental disorder

                                                                    ii. Chronic fatigue syndrome
 If you have any questions regarding any aspect
 of the Benefits described in this Benefit Rider,                   iii. Attention-deficit/hyperactivity disorder
 please call the Behavioral Health AdvocatesSM
                                                                    iv. When performed primarily for
 weekdays, from 8:00 a. m. to 6:00 p. m. at 801-
                                                                        educational purposes
 442-1989 (Salt Lake area) or 800-876-1989.
                                                                    v. When performed in association with
2. Using participating Mental Health providers.                        vocational counseling or training
 Mental health Services will be covered only when
                                                                    vi. Learning disability
 rendered by a Participating Provider unless otherwise
 noted on your Member Payment Summary.                              vii. Mental retardation

3. Services requiring preauthorization.                             viii. Tourette's syndrome

 Preauthorization is required for all mental health and         4.2 in addition, Services for the following
 chemical dependency Services with the exception of             diagnoses are not covered:
 office visits. If you need to request Preauthorization, call     a. Adjustment disorder;
 the Behavioral Health Advocates. Refer to Section 11 –
                                                                  b. Chronic organic brain syndrome;
 “Healthcare Management” for additional information.
                                                                  c. Conduct disorder;
4. exclusions.
                                                                  d. Diagnoses that refer to someone else’s illness,
4.1 the following Services are not covered:




                                                                                                                                mental health/chemical dependency benefit rider
                                                                     such as family history of psychiatric condition,
  a. Behavior modification;                                          family history of mental retardation, family
                                                                     disruption, and/or alcoholism in the family;
  b. Biofeedback;
                                                                  e. Difficult life circumstance not part of
  c. Counseling with a patient’s family, friend(s), employer,        treatment for a recognized mental illness;
     school authorities, or others, except for approved
     medically necessary collateral visits, with or without       f. Marital or family problems;
     the patient present, in connection with otherwise
     covered treatment of the patient’s mental illness;           g. Mental retardation;

  d. Education or training;                                       h. Personality disorder;

  e. Electrosleep or electronarcosis therapy;                     i. Psychosexual disorder such as transsexualism,
                                                                     psychosexual identity disorder, psychosexual
  f. Family counseling and/or therapy;                               dysfunction, or gender dysphoria;

  g. Long-term care;                                              j. Problems with gambling, theft, or fire setting;

  h. Marriage counseling and/or therapy;                          k. Screening exams;

  i. Methadone maintenance/therapy clinics or Services;           l. Separation anxiety;

  j. Milieu therapy;                                             m. Social, occupational, religious, or other
                                                                    social maladjustment; and
  k. Psychotherapy or psychoanalysis credited
     toward earning a degree or furthering                        n. Specific developmental disorder or learning disabilities
     your education or training;                                     such as autism, attention-deficit/hyperactivity
                                                                     disorder, and pervasive developmental disorder.
  l. Residential treatment (except as otherwise
     indicated on your Member Payment Summary);



LE-CERT HMO 01/01/10
DAVIS SCHOOL DIST WAIVER OF PREMIUM                                                                                                                            G1007099 1003 L30A2719 01/01/2010
                                                                                                                                                                     MEMBER PAYMENT SUMMARY
                                                                                                                                                                                  PARTICIPATING
                                                                                                                                                                                         (In-Network)
                                                                                                                                                        When using participating providers, you are responsible to pay the amounts in this column.
                                                                                                                                                            Services from nonparticipating providers are not covered (except emergencies).


CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment - Per Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                     None
Pre-Existing Conditions (PEC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                        None
Benefit Accumulator Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                               calendar year
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET                                                                                                                                           PARTICIPATING
Deductible - Per Person/Family (per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              $500/$1000
Out-of-Pocket Maximum - Per Person/Family (per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                           $1000/$3000
                                                                                                                                                                                      (Deductible Included)
INPATIENT SERVICES                                                                                                                                                                     PARTICIPATING
Medical, Surgical, Hospice, and Emergency Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                               10% after deductible

                                     1
Maternity and Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                             10% after deductible


Skilled Nursing Facility - Up to 60 days per calendar year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             10% after deductible


Inpatient Rehab Therapy: Physical, Speech, Occupational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              10% after deductible
  Up to 40 days per calendar year for all therapy types combined
PROFESSIONAL SERVICES                                                                                                                                                                  PARTICIPATING
Office Visits & Minor Office Surgeries
                                                          2
             Primary Care Provider (PCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           $25
                                                              2
             Secondary Care Provider (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             $35
Preventive Care
                                                          2
             Primary Care Provider (PCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           $25
                                                              2
             Secondary Care Provider (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             $35
             Adult and Pediatric Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                     Covered 100%
             Elective Immunizations - herpes zoster (shingles), rotavirus . . . . . . . . . . . . . . . . . . . . . . . .                                                                        10%
                                                  3
             Diagnostic Tests: Minor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                Covered 100%
Allergy Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                               See Office Visits Above
Allergy Treatment and Serum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                        10%
Major Office Surgery (Surgical and Endoscopic Services Over $350) . . . . . . . . . . . . . . . . . . . . . . .                                                                                  10%
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              10% after deductible
OUTPATIENT SERVICES                                                                                                                                                                    PARTICIPATING
Outpatient Facility and Ambulatory Surgical - (all related services) . . . . . . . . . . . . . . . . . . . . . . . . .                                                                 10% after deductible
Ambulance (Air or Ground) - Emergencies Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           10% after deductible
Emergency Room - (Participating facility) - Includes all services rendered in conjunction with the ER . . . . . . . . . . . . .                                                                  $75
Emergency Room - (Nonparticipating facility) - Includes all services rendered in conjunction with the ER . . . . . . . . . . .                                                                   $125
Intermountain InstaCareSM Facilities, Urgent Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                       $35
Intermountain KidsCareSM Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                          $25
Chemotherapy, Radiation and Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                   10% after deductible
                                     3
Diagnostic Tests: Minor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                Covered 100%
                                     3
Diagnostic Tests: Major . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                            10% after deductible
Home Health, Hospice, Outpatient Private Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                         10% after deductible
Outpatient Rehab Therapy: Physical, Speech, Occupational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                 $35 after deductible
     Up to 20 visits per calendar year for each therapy type

MPS-HMO 01/01/10                                                                                                                                                                       See other side for additional benefits
DAVIS SCHOOL DIST WAIVER OF PREMIUM                                                                                                                            G1007099 1003 L30A2719 01/01/2010
                                                                                                                                                                    MEMBER PAYMENT SUMMARY

                                                                                                                                                                              PARTICIPATING
                                                                                                                                                                                   (In-Network)
MISCELLANEOUS SERVICES                                                                                                                                                            PARTICIPATING
                                                         4
Durable Medical Equipment (DME)                              ................................................                                                                    10% after deductible
Infertility - Selected Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                  *50% after deductible
       (Max Plan Payment $1,500/ calendar year; $5,000 lifetime)
Miscellaneous Medical Supplies (MMS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                 10% after deductible
Other Plan Payment Maximums
     Cochlear Implants - Up to $35,000 lifetime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          See Physician’s Fees and Inpatient or Outpatient Services benefits
     Donor Fees for Covered Organ Transplants - Up to $40,000 lifetime . . . . . . . . . . . . . . . . . . . . .                                                                 10% after deductible
     TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime . . . . . . . . . . . . . . . . . . . . . . .                                                                10% after deductible
BENEFIT RIDERS                                                                                                                                                                   PARTICIPATING
                                                                7
Mental Health and Chemical Dependency
     Mental Health Office Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                             $25
     Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         10% after deductible
     Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                            10% after deductible
                                        7
     Residential Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                     10% after deductible
Injectable Drugs and Specialty Medications + . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                 10% after deductible
PRESCRIPTION DRUGS
Prescription Drugs - Up to 30 Day Supply of Covered Medications +
     Tier 1                                                                                                                                                                              *$10
     Tier 2                                                                                                                                                                              *$20
     Tier 3                                                                                                                                                                              *$40
Maintenance Drug Benefit-90 Day Supply (Medco by Mail or Retail90SM)-selected drugs +
     Tier 1                                                                                                                                                                              *$20
     Tier 2                                                                                                                                                                              *$40
     Tier 3                                                                                                                                                                              *$80
Generic Substitution Required                                                                                                                                        Generic required or must pay copay plus cost
                                                                                                                                                                      difference between name brand and generic

1 SelectHealth provides an allowable adoption amount of $4,000 as outlined by the state of Utah. Medical deductible and copay/coinsurance applies.
2 Refer to your SelectHealth Provider & Facility Directory to identify whether a provider is a primary or secondary care provider.
3 Refer to your Certificate of Coverage for more information.
4 Certain DME items require preauthorization for coverage. Refer to your Certificate of Coverage, or contact SelectHealth Member Services for more information.
7 All mental health and chemical dependency services require preauthorization with the exception of office visits.
+ Preauthorization is required on certain injectable and prescription drugs. If you fail to preauthorize, the drug will not be covered. Please refer to your Certificate of
Coverage for more information.
* Not applied to Medical out-of-pocket maximum.



All deductible/copay/coinsurance amounts and plan payments are based on allowed amounts only and not on the provider's billed or other charges. You are responsible to
pay for charges in excess of allowed amounts for covered services obtained from non-participating providers and facilities. Such excess charges are not applied to the
medical out-of-pocket maximum. Refer to your Contract, Certificate of Coverage, or Provider & Facility Directory for more information.


Select Med is administered and underwritten by SelectHealth.
MPS-HMO 01/01/10                v2-0                                                                                                                                                                                            C
09/18/09                                                                                                                                                                                                 www.selecthealth.org
DAVIS SCHOOL DISTRICT RETIREE                                                                                                                                  G1007099 1002 L30A2719 01/01/2010
                                                                                                                                                                     MEMBER PAYMENT SUMMARY
                                                                                                                                                                                  PARTICIPATING
                                                                                                                                                                                         (In-Network)
                                                                                                                                                        When using participating providers, you are responsible to pay the amounts in this column.
                                                                                                                                                            Services from nonparticipating providers are not covered (except emergencies).


CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment - Per Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                     None
Pre-Existing Conditions (PEC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                        None
Benefit Accumulator Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                               calendar year
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET                                                                                                                                           PARTICIPATING
Deductible - Per Person/Family (per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              $500/$1000
Out-of-Pocket Maximum - Per Person/Family (per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                           $1000/$3000
                                                                                                                                                                                      (Deductible Included)
INPATIENT SERVICES                                                                                                                                                                     PARTICIPATING
Medical, Surgical, Hospice, and Emergency Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                               10% after deductible

                                     1
Maternity and Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                             10% after deductible


Skilled Nursing Facility - Up to 60 days per calendar year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             10% after deductible


Inpatient Rehab Therapy: Physical, Speech, Occupational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              10% after deductible
  Up to 40 days per calendar year for all therapy types combined
PROFESSIONAL SERVICES                                                                                                                                                                  PARTICIPATING
Office Visits & Minor Office Surgeries
                                                          2
             Primary Care Provider (PCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           $25
                                                              2
             Secondary Care Provider (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             $35
Preventive Care
                                                          2
             Primary Care Provider (PCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           $25
                                                              2
             Secondary Care Provider (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             $35
             Adult and Pediatric Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                     Covered 100%
             Elective Immunizations - herpes zoster (shingles), rotavirus . . . . . . . . . . . . . . . . . . . . . . . .                                                                        10%
                                                  3
             Diagnostic Tests: Minor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                Covered 100%
Allergy Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                               See Office Visits Above
Allergy Treatment and Serum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                        10%
Major Office Surgery (Surgical and Endoscopic Services Over $350) . . . . . . . . . . . . . . . . . . . . . . .                                                                                  10%
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              10% after deductible
OUTPATIENT SERVICES                                                                                                                                                                    PARTICIPATING
Outpatient Facility and Ambulatory Surgical - (all related services) . . . . . . . . . . . . . . . . . . . . . . . . .                                                                 10% after deductible
Ambulance (Air or Ground) - Emergencies Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           10% after deductible
Emergency Room - (Participating facility) - Includes all services rendered in conjunction with the ER . . . . . . . . . . . . .                                                                  $75
Emergency Room - (Nonparticipating facility) - Includes all services rendered in conjunction with the ER . . . . . . . . . . .                                                                   $125
Intermountain InstaCareSM Facilities, Urgent Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                       $35
Intermountain KidsCareSM Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                          $25
Chemotherapy, Radiation and Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                   10% after deductible
                                     3
Diagnostic Tests: Minor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                Covered 100%
                                     3
Diagnostic Tests: Major . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                            10% after deductible
Home Health, Hospice, Outpatient Private Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                         10% after deductible
Outpatient Rehab Therapy: Physical, Speech, Occupational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                 $35 after deductible
     Up to 20 visits per calendar year for each therapy type

MPS-HMO 01/01/10                                                                                                                                                                       See other side for additional benefits
DAVIS SCHOOL DISTRICT RETIREE                                                                                                                                  G1007099 1002 L30A2719 01/01/2010
                                                                                                                                                                    MEMBER PAYMENT SUMMARY

                                                                                                                                                                              PARTICIPATING
                                                                                                                                                                                   (In-Network)
MISCELLANEOUS SERVICES                                                                                                                                                            PARTICIPATING
                                                         4
Durable Medical Equipment (DME)                              ................................................                                                                    10% after deductible
Infertility - Selected Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                  *50% after deductible
       (Max Plan Payment $1,500/ calendar year; $5,000 lifetime)
Miscellaneous Medical Supplies (MMS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                 10% after deductible
Other Plan Payment Maximums
     Cochlear Implants - Up to $35,000 lifetime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          See Physician’s Fees and Inpatient or Outpatient Services benefits
     Donor Fees for Covered Organ Transplants - Up to $40,000 lifetime . . . . . . . . . . . . . . . . . . . . .                                                                 10% after deductible
     TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime . . . . . . . . . . . . . . . . . . . . . . .                                                                10% after deductible
BENEFIT RIDERS                                                                                                                                                                   PARTICIPATING
                                                                7
Mental Health and Chemical Dependency
     Mental Health Office Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                             $25
     Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         10% after deductible
     Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                            10% after deductible
                                        7
     Residential Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                     10% after deductible
Injectable Drugs and Specialty Medications + . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                 10% after deductible
PRESCRIPTION DRUGS
Prescription Drugs - Up to 30 Day Supply of Covered Medications +
     Tier 1                                                                                                                                                                              *$10
     Tier 2                                                                                                                                                                              *$20
     Tier 3                                                                                                                                                                              *$40
Maintenance Drug Benefit-90 Day Supply (Medco by Mail or Retail90SM)-selected drugs +
     Tier 1                                                                                                                                                                              *$20
     Tier 2                                                                                                                                                                              *$40
     Tier 3                                                                                                                                                                              *$80
Generic Substitution Required                                                                                                                                        Generic required or must pay copay plus cost
                                                                                                                                                                      difference between name brand and generic

1 SelectHealth provides an allowable adoption amount of $4,000 as outlined by the state of Utah. Medical deductible and copay/coinsurance applies.
2 Refer to your SelectHealth Provider & Facility Directory to identify whether a provider is a primary or secondary care provider.
3 Refer to your Certificate of Coverage for more information.
4 Certain DME items require preauthorization for coverage. Refer to your Certificate of Coverage, or contact SelectHealth Member Services for more information.
7 All mental health and chemical dependency services require preauthorization with the exception of office visits.
+ Preauthorization is required on certain injectable and prescription drugs. If you fail to preauthorize, the drug will not be covered. Please refer to your Certificate of
Coverage for more information.
* Not applied to Medical out-of-pocket maximum.



All deductible/copay/coinsurance amounts and plan payments are based on allowed amounts only and not on the provider's billed or other charges. You are responsible to
pay for charges in excess of allowed amounts for covered services obtained from non-participating providers and facilities. Such excess charges are not applied to the
medical out-of-pocket maximum. Refer to your Contract, Certificate of Coverage, or Provider & Facility Directory for more information.


Select Med is administered and underwritten by SelectHealth.
MPS-HMO 01/01/10                v2-0                                                                                                                                                                                            C
09/18/09                                                                                                                                                                                                 www.selecthealth.org
DAVIS SCHOOL DISTRICT - COBRA                                                                                                                                  G1007099 1005 L30A2719 01/01/2010
                                                                                                                                                                     MEMBER PAYMENT SUMMARY
                                                                                                                                                                                  PARTICIPATING
                                                                                                                                                                                         (In-Network)
                                                                                                                                                        When using participating providers, you are responsible to pay the amounts in this column.
                                                                                                                                                            Services from nonparticipating providers are not covered (except emergencies).


CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment - Per Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                     None
Pre-Existing Conditions (PEC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                        None
Benefit Accumulator Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                               calendar year
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET                                                                                                                                           PARTICIPATING
Deductible - Per Person/Family (per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              $500/$1000
Out-of-Pocket Maximum - Per Person/Family (per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                           $1000/$3000
                                                                                                                                                                                      (Deductible Included)
INPATIENT SERVICES                                                                                                                                                                     PARTICIPATING
Medical, Surgical, Hospice, and Emergency Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                               10% after deductible

                                     1
Maternity and Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                             10% after deductible


Skilled Nursing Facility - Up to 60 days per calendar year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             10% after deductible


Inpatient Rehab Therapy: Physical, Speech, Occupational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              10% after deductible
  Up to 40 days per calendar year for all therapy types combined
PROFESSIONAL SERVICES                                                                                                                                                                  PARTICIPATING
Office Visits & Minor Office Surgeries
                                                          2
             Primary Care Provider (PCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           $25
                                                              2
             Secondary Care Provider (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             $35
Preventive Care
                                                          2
             Primary Care Provider (PCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           $25
                                                              2
             Secondary Care Provider (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             $35
             Adult and Pediatric Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                     Covered 100%
             Elective Immunizations - herpes zoster (shingles), rotavirus . . . . . . . . . . . . . . . . . . . . . . . .                                                                        10%
                                                  3
             Diagnostic Tests: Minor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                Covered 100%
Allergy Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                               See Office Visits Above
Allergy Treatment and Serum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                        10%
Major Office Surgery (Surgical and Endoscopic Services Over $350) . . . . . . . . . . . . . . . . . . . . . . .                                                                                  10%
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              10% after deductible
OUTPATIENT SERVICES                                                                                                                                                                    PARTICIPATING
Outpatient Facility and Ambulatory Surgical - (all related services) . . . . . . . . . . . . . . . . . . . . . . . . .                                                                 10% after deductible
Ambulance (Air or Ground) - Emergencies Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           10% after deductible
Emergency Room - (Participating facility) - Includes all services rendered in conjunction with the ER . . . . . . . . . . . . .                                                                  $75
Emergency Room - (Nonparticipating facility) - Includes all services rendered in conjunction with the ER . . . . . . . . . . .                                                                   $125
Intermountain InstaCareSM Facilities, Urgent Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                       $35
Intermountain KidsCareSM Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                          $25
Chemotherapy, Radiation and Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                   10% after deductible
                                     3
Diagnostic Tests: Minor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                Covered 100%
                                     3
Diagnostic Tests: Major . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                            10% after deductible
Home Health, Hospice, Outpatient Private Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                         10% after deductible
Outpatient Rehab Therapy: Physical, Speech, Occupational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                 $35 after deductible
     Up to 20 visits per calendar year for each therapy type

MPS-HMO 01/01/10                                                                                                                                                                       See other side for additional benefits
DAVIS SCHOOL DISTRICT - COBRA                                                                                                                                  G1007099 1005 L30A2719 01/01/2010
                                                                                                                                                                    MEMBER PAYMENT SUMMARY

                                                                                                                                                                              PARTICIPATING
                                                                                                                                                                                   (In-Network)
MISCELLANEOUS SERVICES                                                                                                                                                            PARTICIPATING
                                                         4
Durable Medical Equipment (DME)                              ................................................                                                                    10% after deductible
Infertility - Selected Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                  *50% after deductible
       (Max Plan Payment $1,500/ calendar year; $5,000 lifetime)
Miscellaneous Medical Supplies (MMS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                 10% after deductible
Other Plan Payment Maximums
     Cochlear Implants - Up to $35,000 lifetime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          See Physician’s Fees and Inpatient or Outpatient Services benefits
     Donor Fees for Covered Organ Transplants - Up to $40,000 lifetime . . . . . . . . . . . . . . . . . . . . .                                                                 10% after deductible
     TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime . . . . . . . . . . . . . . . . . . . . . . .                                                                10% after deductible
BENEFIT RIDERS                                                                                                                                                                   PARTICIPATING
                                                                7
Mental Health and Chemical Dependency
     Mental Health Office Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                             $25
     Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         10% after deductible
     Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                            10% after deductible
                                        7
     Residential Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                     10% after deductible
Injectable Drugs and Specialty Medications + . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                 10% after deductible
PRESCRIPTION DRUGS
Prescription Drugs - Up to 30 Day Supply of Covered Medications +
     Tier 1                                                                                                                                                                              *$10
     Tier 2                                                                                                                                                                              *$20
     Tier 3                                                                                                                                                                              *$40
Maintenance Drug Benefit-90 Day Supply (Medco by Mail or Retail90SM)-selected drugs +
     Tier 1                                                                                                                                                                              *$20
     Tier 2                                                                                                                                                                              *$40
     Tier 3                                                                                                                                                                              *$80
Generic Substitution Required                                                                                                                                        Generic required or must pay copay plus cost
                                                                                                                                                                      difference between name brand and generic

1 SelectHealth provides an allowable adoption amount of $4,000 as outlined by the state of Utah. Medical deductible and copay/coinsurance applies.
2 Refer to your SelectHealth Provider & Facility Directory to identify whether a provider is a primary or secondary care provider.
3 Refer to your Certificate of Coverage for more information.
4 Certain DME items require preauthorization for coverage. Refer to your Certificate of Coverage, or contact SelectHealth Member Services for more information.
7 All mental health and chemical dependency services require preauthorization with the exception of office visits.
+ Preauthorization is required on certain injectable and prescription drugs. If you fail to preauthorize, the drug will not be covered. Please refer to your Certificate of
Coverage for more information.
* Not applied to Medical out-of-pocket maximum.



All deductible/copay/coinsurance amounts and plan payments are based on allowed amounts only and not on the provider's billed or other charges. You are responsible to
pay for charges in excess of allowed amounts for covered services obtained from non-participating providers and facilities. Such excess charges are not applied to the
medical out-of-pocket maximum. Refer to your Contract, Certificate of Coverage, or Provider & Facility Directory for more information.


Select Med is administered and underwritten by SelectHealth.
MPS-HMO 01/01/10                v2-0                                                                                                                                                                                            C
09/18/09                                                                                                                                                                                                 www.selecthealth.org
DAVIS SCHOOL DISTRICT                                                                                                                                          G1007099 1001 L30A2719 01/01/2010
                                                                                                                                                                     MEMBER PAYMENT SUMMARY
                                                                                                                                                                                  PARTICIPATING
                                                                                                                                                                                         (In-Network)
                                                                                                                                                        When using participating providers, you are responsible to pay the amounts in this column.
                                                                                                                                                            Services from nonparticipating providers are not covered (except emergencies).


CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment - Per Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                     None
Pre-Existing Conditions (PEC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                        None
Benefit Accumulator Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                               calendar year
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET                                                                                                                                           PARTICIPATING
Deductible - Per Person/Family (per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              $500/$1000
Out-of-Pocket Maximum - Per Person/Family (per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                           $1000/$3000
                                                                                                                                                                                      (Deductible Included)
INPATIENT SERVICES                                                                                                                                                                     PARTICIPATING
Medical, Surgical, Hospice, and Emergency Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                               10% after deductible

                                     1
Maternity and Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                             10% after deductible


Skilled Nursing Facility - Up to 60 days per calendar year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             10% after deductible


Inpatient Rehab Therapy: Physical, Speech, Occupational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              10% after deductible
  Up to 40 days per calendar year for all therapy types combined
PROFESSIONAL SERVICES                                                                                                                                                                  PARTICIPATING
Office Visits & Minor Office Surgeries
                                                          2
             Primary Care Provider (PCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           $25
                                                              2
             Secondary Care Provider (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             $35
Preventive Care
                                                          2
             Primary Care Provider (PCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           $25
                                                              2
             Secondary Care Provider (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                             $35
             Adult and Pediatric Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                     Covered 100%
             Elective Immunizations - herpes zoster (shingles), rotavirus . . . . . . . . . . . . . . . . . . . . . . . .                                                                        10%
                                                  3
             Diagnostic Tests: Minor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                Covered 100%
Allergy Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                               See Office Visits Above
Allergy Treatment and Serum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                        10%
Major Office Surgery (Surgical and Endoscopic Services Over $350) . . . . . . . . . . . . . . . . . . . . . . .                                                                                  10%
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                              10% after deductible
OUTPATIENT SERVICES                                                                                                                                                                    PARTICIPATING
Outpatient Facility and Ambulatory Surgical - (all related services) . . . . . . . . . . . . . . . . . . . . . . . . .                                                                 10% after deductible
Ambulance (Air or Ground) - Emergencies Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                           10% after deductible
Emergency Room - (Participating facility) - Includes all services rendered in conjunction with the ER . . . . . . . . . . . . .                                                                  $75
Emergency Room - (Nonparticipating facility) - Includes all services rendered in conjunction with the ER . . . . . . . . . . .                                                                   $125
Intermountain InstaCareSM Facilities, Urgent Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                       $35
Intermountain KidsCareSM Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                          $25
Chemotherapy, Radiation and Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                   10% after deductible
                                     3
Diagnostic Tests: Minor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                Covered 100%
                                     3
Diagnostic Tests: Major . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                            10% after deductible
Home Health, Hospice, Outpatient Private Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                         10% after deductible
Outpatient Rehab Therapy: Physical, Speech, Occupational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                 $35 after deductible
     Up to 20 visits per calendar year for each therapy type

MPS-HMO 01/01/10                                                                                                                                                                       See other side for additional benefits
DAVIS SCHOOL DISTRICT                                                                                                                                          G1007099 1001 L30A2719 01/01/2010
                                                                                                                                                                    MEMBER PAYMENT SUMMARY

                                                                                                                                                                              PARTICIPATING
                                                                                                                                                                                   (In-Network)
MISCELLANEOUS SERVICES                                                                                                                                                            PARTICIPATING
                                                         4
Durable Medical Equipment (DME)                              ................................................                                                                    10% after deductible
Infertility - Selected Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                  *50% after deductible
       (Max Plan Payment $1,500/ calendar year; $5,000 lifetime)
Miscellaneous Medical Supplies (MMS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                 10% after deductible
Other Plan Payment Maximums
     Cochlear Implants - Up to $35,000 lifetime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          See Physician’s Fees and Inpatient or Outpatient Services benefits
     Donor Fees for Covered Organ Transplants - Up to $40,000 lifetime . . . . . . . . . . . . . . . . . . . . .                                                                 10% after deductible
     TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime . . . . . . . . . . . . . . . . . . . . . . .                                                                10% after deductible
BENEFIT RIDERS                                                                                                                                                                   PARTICIPATING
                                                                7
Mental Health and Chemical Dependency
     Mental Health Office Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                             $25
     Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         10% after deductible
     Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                            10% after deductible
                                        7
     Residential Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                     10% after deductible
Injectable Drugs and Specialty Medications + . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                 10% after deductible
PRESCRIPTION DRUGS
Prescription Drugs - Up to 30 Day Supply of Covered Medications +
     Tier 1                                                                                                                                                                              *$10
     Tier 2                                                                                                                                                                              *$20
     Tier 3                                                                                                                                                                              *$40
Maintenance Drug Benefit-90 Day Supply (Medco by Mail or Retail90SM)-selected drugs +
     Tier 1                                                                                                                                                                              *$20
     Tier 2                                                                                                                                                                              *$40
     Tier 3                                                                                                                                                                              *$80
Generic Substitution Required                                                                                                                                        Generic required or must pay copay plus cost
                                                                                                                                                                      difference between name brand and generic

1 SelectHealth provides an allowable adoption amount of $4,000 as outlined by the state of Utah. Medical deductible and copay/coinsurance applies.
2 Refer to your SelectHealth Provider & Facility Directory to identify whether a provider is a primary or secondary care provider.
3 Refer to your Certificate of Coverage for more information.
4 Certain DME items require preauthorization for coverage. Refer to your Certificate of Coverage, or contact SelectHealth Member Services for more information.
7 All mental health and chemical dependency services require preauthorization with the exception of office visits.
+ Preauthorization is required on certain injectable and prescription drugs. If you fail to preauthorize, the drug will not be covered. Please refer to your Certificate of
Coverage for more information.
* Not applied to Medical out-of-pocket maximum.



All deductible/copay/coinsurance amounts and plan payments are based on allowed amounts only and not on the provider's billed or other charges. You are responsible to
pay for charges in excess of allowed amounts for covered services obtained from non-participating providers and facilities. Such excess charges are not applied to the
medical out-of-pocket maximum. Refer to your Contract, Certificate of Coverage, or Provider & Facility Directory for more information.


Select Med is administered and underwritten by SelectHealth.
MPS-HMO 01/01/10                v2-0                                                                                                                                                                                            C
09/18/09                                                                                                                                                                                                 www.selecthealth.org

								
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