Health Savings Account Eligible Plans

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1 Health Savings Account Eligible Plans Secure WELL TH Choices 100% PLAN PREMIUM SAVER NO WORRIES KNOW YOUR COSTS $0 copay yearly women s health checkup $0 copay routine pap smear and mammogram $0 copay well child exam $0 copay adult routine preventive care $0 copay preventive care prescription drugs $0 copay certain diabetic supplies and insulin $0 copay child vision exam Free pair of child eyeglasses per year * $2,500 Individual $5,000 Family* $1,750 Individual $3,500 Family $1,500 Individual $3,000 Family - Primary Care Office Visit $20 - Specialist Office Visit $60 $30 $60 - Prescriptions - Preferred Brand $0 out of pocket * $6,350 Individual $12,700 Family* $5,000 Individual,000 Family $5,000 Individual,000 Family HEALTH SAVINGS ACCOUNT ELIGIBLE? Yes Yes Yes Yes *Individual deductible/out-of-pocket max applies to any one family member **Copay waived after three consecutive hospital days This summary is for illustrative purposes only. Benefits shown are for Arches Horizon Network Preferred Providers. All products shown are HMO plans and do not generally provide benefits outside of the preferred network. Urgent and emergency care benefits provided when required by unavoidable circumstances. For costs and complete detail of coverage, including limitations and exclusions, contact Arches Health Plan at , or contact your insurance agent.

2 Healthy Lifestyle Plans Healthy Lifestyle Plan Choices JUST THE BASICS HEALTHY LIFESTYLE ELEVATED All plans offer free yearly women s health checkups, free routine pap smear and mammograms, free routine preventative care, certain free preventative prescription drugs, and certain free diabetic supplies and insulin. Children receive free yearly well checks, a free yearly vision exam, and, if needed, a free pair of eyeglasses. See additional first-dollar benefits below: copay primary copay for first calendar year visit primary care copays for first three calendar year visits preferred generic prescriptions coinsurance for preferred brand name prescriptions Deductible waived in case of accident Medical services must be provided within 90 days from the date of the accident - Primary Care Office Visit - Specialist Office Visit - Prescriptions - Preferred Brand HEALTH SAVINGS ACCOUNT ELIGIBLE? $5,000 Individual,000 Family $6,350 Individual $12,700 Family $2,500 Individual $5,000 Family $60 This summary is for illustrative purposes only. Benefits shown are for Arches Horizon Network Preferred Providers. All products shown are HMO plans and do not generally provide benefits outside of the preferred network. Urgent and emergency care benefits provided when required by unavoidable circumstances. For costs and complete detail of coverage, including limitations and exclusions, contact Arches Health Plan at , or contact your insurance agent.

3 Traditional Health Plans Traditional Plan Choices KNOW YOUR COSTS BALANCED LIFE Metallic Certified: Gold CLASSIC NO WORRY BENEFITS Metallic Certified: Gold KNOW YOUR COSTS LOW DEDUCTIBLE All plans offer free yearly women s health checkups, free routine pap smear and mammograms, free routine preventative care, certain free preventative prescription drugs, and certain free diabetic supplies and insulin. Children receive free yearly well checks, a free yearly vision exam, and, if needed, a free pair of eyeglasses. - Primary Care Office Visit - Specialist Office Visit - Prescriptions - Preferred Brand Deductible waived in case of accident Medical services must be provided within 90 days from the date of the accident $2,000 Individual $4,000 Family 0 Individual $1,000 Family 0 Individual 0 Family $5,000 Individual,000 Family HEALTH SAVINGS ACCOUNT ELIGIBLE? **Copay waived after three consecutive hospital days **Copay waived after three consecutive hospital days This summary is for illustrative purposes only. Benefits shown are for Arches Horizon Network Preferred Providers. All products shown are HMO plans and do not generally provide benefits outside of the preferred network. Urgent and emergency care benefits provided when required by unavoidable circumstances. For costs and complete detail of coverage, including limitations and exclusions, contact Arches Health Plan at , or contact your insurance agent.

4 Patient-Centered Health Home Plans Preferred Care Clinic Plans JUST THE BASICS $5 copay first two yearly preferred care primary physician visits $0 copay yearly women s health checkup $0 copay routine pap smear and mammogram $0 copay well child exam $0 copay adult routine preventive care $0 copay preventive care prescription drugs $0 copay certain diabetic supplies and insulin $0 copay child vision exam Free pair of child eyeglasses per year SMART SAVER Includes all Just the Basics benefits, plus the following: $5 copay preferred care clinic primary physician copay all other participating providers copay urgent care $5 copay preferred generic prescriptions copay preferred brand name prescriptions copay mental health Deductible waived in case of accident Medical services must be provided within 90 days from the date of the accident $5,000 Individual /,000 Family $3,000 Individual / $6,000 Family - Preferred Care Clinic Primary Physician $5 - Office Visits for All Other Participating Providers $5 - Prescriptions - Preferred Brand Name HEALTH SAVINGS ACCOUNT ELIGIBLE? : $6,350 Individual $12,700 Family **Copay waived after three consecutive hospital days This summary is for illustrative purposes only. Benefits shown are for Arches Horizon Network Preferred Providers. All products shown are HMO plans and do not generally provide benefits outside of the preferred network. Urgent and emergency care benefits provided when required by unavoidable circumstances. For costs and complete detail of coverage, including limitations and exclusions, contact Arches Health Plan at , or contact your insurance agent.

5 Patient-Centered Health Home Plans Community Health Plans JUST THE BASICS $5 copay first two community health ctr primary physician visits $0 copay yearly women s health checkup $0 copay routine pap smear and mammogram $0 copay well child exam $0 copay adult routine preventive care $0 copay preventive care prescription drugs $0 copay certain diabetic supplies and insulin $0 copay child vision exam Free pair of child eyeglasses per year SMART SAVER Includes all Just the Basics benefits, plus the following: $5 copay community health center primary physician copay all other participating providers copay urgent care $5 copay preferred generic prescriptions copay preferred brand name prescriptions copay mental health Deductible waived in case of accident Medical services must be provided within 90 days from the date of the accident $5,000 Individual /,000 Family $3,000 Individual / $6,000 Family - Community Health Center Visit $5 - Office Visits for All Other Participating Providers $5 - Prescriptions - Preferred Brand Name HEALTH SAVINGS ACCOUNT ELIGIBLE? : $6,350 Individual $12,700 Family **Copay waived after three consecutive hospital days This summary is for illustrative purposes only. Benefits shown are for Arches Horizon Network Preferred Providers. All products shown are HMO plans and do not generally provide benefits outside of the preferred network. Urgent and emergency care benefits provided when required by unavoidable circumstances. For costs and complete detail of coverage, including limitations and exclusions, contact Arches Health Plan at , or contact your insurance agent.

6 Preferred Care Clinic Providers HOSPITALS PREFERRED CARE CLINICS NORTHERN UTAH Cache and Rich Counties Bear River Valley Hospital, Tremonton Cache Valley Specialty Hospital, Logan Logan Regional Hospital, Logan Providence Family Medicine, Providence Cache Valley Women's Center, Logan Bear River Medical Arts, Bear River Bear Lake CHC, Garden City Cache Valley CHC, Logan Southern Cache Valley CHC, Hyrum NORTHERN WASATCH FRONT Box Elder and Weber Counties Brigham City Community Hospital, Brigham City Ogden Regional Medical Center, Ogden Medical Arts Center Clinic, Brigham City Mt. Star Brigham Center for Women, Brigham City Mt. Star South Ogden Center for Family Medicine Mt. Star Primary Care, Ogden Mt. Star Ogden Internal Medicine Mt. Star Ogden Pediatrics Morgan Health Center, Morgan CENTRAL WASATCH FRONT Davis, Salt Lake, Tooele and Summit Counties Davis Hospital & Medial Center, Layton Jordan Valley Medical Center,West Jordan Lakeview Hospital, Bountiful Lone Peak Hospital, Draper Mountain West Medical Center, Tooele Park City Medical Center, Park City Pioneer Valley Hospital, West Valley City Primary Children's Medical Center, Salt Lake Regional Medical Center, St. Mark's Hospital, University of Utah Medical Center, University of Utah Huntsman Cancer Institute, WeeCare Pediatrics, Layton, Kaysville, Syracuse U of U Primary Care, Centerville, Stansbury Park Westside Medical, Clinton Davis Family Physicians, Layton Layton Family Medicine, Layton Cope Family Clinic, Bountiful Lakeview Internal Medicine, Bountiful Wasatch Pediatrics, Bountiful Millcreek Primary Care, Alta Internal Medicine, Draper U of U Primary Care, South Jordan, Greenwood, Midvale U of U Primary Care, Sugarhouse, Westridge, Madsen, Redwood Granger Medical, West Jordan, Riverton Olympus Clinic, Wasatch Internal Medicine, Wasatch Pediatrics, St. Marks, Cottonwood, Draper, Murray, West Jordan U of U Primary Care, Redstone Wasatch Pediatrics, Park City CENTRAL AND SOUTHWESTERN UTAH Utah County and South I-15 Corridor Counties Timpanogos Regional Hospital, Orem Utah Valley Regional Medical Center, Provo (with pre-authorization) Mountain View Hospital, Payson Central Valley Medical Center, Nephi Sanpete Valley Hospital, Mount Pleasant Delta Community Medical Center, Delta Gunnison Valley Hospital, Gunnison Fillmore Community Medical Center, Fillmore Beaver Valley Hospital, Beaver Milford Memorial Hospital, Milford Sevier Valley Medical Center, Richfield Garfield Memorial Hospital, Panguitch Valley View Medical Center, Cedar City Dixie Regional Medical Center, St.George Premier Family Medicine, Saratoga Springs, Lehi, American Fork Utah Valley Pediatrics, Sarasota Springs, American Fork, Orem TriCity Medical, Lindon, Pleasant Grove U of U Primary Care, Orem Canyonview Medical, Springville, Spanish Fork, Payson Grandview Family Medicine, Provo Central Valley Medical Clinic, Nephi Beaver Medical Clinic, Beaver, Milford Cedar Ridge Family Medicine, Cedar City Color Country Pediatrics, Cedar City The Cedar City Institute for Womens Health, Cedar City St. George Clinic, Washington, Hurricane Valley Callahan Clinic, St. George Canyonlands Pediatric, St George Dixie Pediatrics, St. George EASTERN UTAH Ashley Regional Medical Center, Vernal Blue Mountain Hospital, Blanding Castleview Hospital, Price Heber Valley Medical Center, Heber City Kane County Hospital, Kanab Moab Regional Hospital, Moab San Juan Hospital Uintah Basin Medical Center, Roosevelt Arches Health Plans are accepted by 86% of Utah hospitals and more than 4,500 preferred providers. To see if your doctor is on our panel, go to Eastern and Southeastern Counties Coalville Health Center, Kamas Coalville Health Center, Coalville Dr. Todd Haderlie, Heber City Dr. Tod Berg, Heber City Dr. Gregory Tayler, Heber City Basin Clinic, Vernal Dinosaur Land Pediatrics, Vernal rtheastern Utah Medical Group, Roosevelt Utah Navajo Health Services, Blanding, Montezuma Creek Utah Navajo Health Services, Monument Valley, Navajo Mountain San Juan Health Services, Blanding, Monticello, Spanish Valley Visit above clinics for $5 primary care physician copay; copay for all other preferred providers

7 Community Health Center Providers HOSPITALS COMMUNITY HEALTH CENTERS NORTHERN UTAH Cache and Rich Counties Bear River Valley Hospital, Tremonton Cache Valley Specialty Hospital, Logan Logan Regional Hospital, Logan Bear Lake Community Health Center, Garden City Cache Valley Community Health Center, Logan Southern Cache Valley Community, Health Center, Hyrum NORTHERN WASATCH FRONT Brigham City Community Hospital, Brigham City Box Elder and Weber Counties Ogden Regional Medical Center, Ogden Midtown CHC Pediatrics, Ogden Midtown CHC Family Medicine, Ogden CENTRAL WASATCH FRONT Davis, Salt Lake, Tooele and Summit Counties Davis Hospital & Medial Center, Layton Jordan Valley Medical Center,West Jordan Lakeview Hospital, Bountiful Lone Peak Hospital, Draper Mountain West Medical Center, Tooele Park City Medical Center, Park City Pioneer Valley Hospital, West Valley City Primary Children's Medical Center, Salt Lake Regional Medical Center, St. Mark's Hospital, University of Utah Medical Center, University of Utah Huntsman Cancer Institute, Sacred Circle Clinic, Midtown Community Health Center, South Salt Lake (coming January) Midtown Community Health Center, Kaysville Stephen D. Radcliffe Community Health Center, St. Marks Family Medicine, CHC Inc, Rosepark,, Midvale, Taylorsville 72nd Street Clinic, Midvale Oquirrh View Community Health Center, West Valley City St. Mark s Family Medicine, Salt Lake City CENTRAL AND SOUTHWESTERN UTAH Utah County and South I-15 Corridor Counties Timpanogos Regional Hospital, Orem Utah Valley Regional Medical Center, Provo (with pre-authorization) Mountain View Hospital, Payson Central Valley Medical Center, Nephi Sanpete Valley Hospital, Mount Pleasant Delta Community Medical Center, Delta Gunnison Valley Hospital, Gunnison Fillmore Community Medical Center, Fillmore Beaver Valley Hospital, Beaver Milford Memorial Hospital, Milford Sevier Valley Medical Center, Richfield Garfield Memorial Hospital, Panguitch Valley View Medical Center, Cedar City Dixie Regional Medical Center, St.George Mountainlands Community Health Center, Provo Payson Family Health Center, Payson Pitu Tribe Clinic, Cedar City Family Healthcare, Cedar City Family Healthcare (Millcreek), St. George Kanoosh Clinic, Kanoosh Koosharem Clinic, Richfield Family Healthcare, St. George Wayne County CHC, Bicknell Shivwits Clinic, Ivins Paiute Clinic, Kanosh EASTERN UTAH Eastern and Southeastern Counties Ashley Regional Medical Center, Vernal Blue Mountain Hospital, Blanding Castleview Hospital, Price Heber Valley Medical Center, Heber City Kane County Hospital, Kanab Moab Regional Hospital, Moab San Juan Hospital Uintah Basin Medical Center, Roosevelt Moab Family Clinic, Moab East Carbon Clinic, East Carbon Monument Valley Community Health Clinic, Monument Valley Montezuma Creek Community Health Clinic, Montezuma Creek Blanding Family Practice, Blanding Navajo Mountain Community Health Clinic, Navajo Mountain Mountainlands, Vernal (coming 2014) Arches Health Plans are accepted by 86% of Utah hospitals and more than 4,500 preferred providers. To see if your doctor is on our panel, go to Visit above clinics for $5 primary care physician copay; copay for all other preferred providers

8 Arches Horizon Network Preferred Providers HOSPITALS Arches Health Plans are accepted by 86 percent of Utah hospitals and more than 4,500 preferred local providers. Arches members are also welcome at thousands of Express Scripts network pharmacies nationwide. To see if your doctor is on our panel, go to: WASATCH FRONT Brigham City Community Hospital, Brigham City Davis Hospital & Medial Center, Layton Jordan Valley Medical Center, West Jordan Lakeview Hospital, Bountiful Lone Peak Hospital, Draper Mountain View Hospital, Payson Mountain West Medical Center, Tooele Ogden Regional Medical Center, Ogden Pioneer Valley Hospital, West Valley City Primary Children's Medical Center, Salt Lake Regional Medical Center, St. Mark's Hospital, Timpanogos Regional Hospital, Orem University of Utah Huntsman Cancer Institute, University of Utah Medical Center, Utah Valley Regional Medical Center, Provo (with pre-authorization) NORTHERN UTAH Bear River Valley Hospital, Tremonton Cache Valley Specialty Hospital, Logan Logan Regional Hospital, Logan CENTRAL AND SOUTHWESTERN UTAH Beaver Valley Hospital, Beaver Central Valley Medical Center, Nephi Delta Community Medical Center, Delta Dixie Regional Medical Center, St.George Fillmore Community Medical Center, Fillmore Garfield Memorial Hospital, Panguitch Gunnison Valley Hospital, Gunnison Milford Memorial Hospital, Milford Sanpete Valley Hospital, Mount Pleasant Sevier Valley Medical Center, Richfield Valley View Medical Center, Cedar City EASTERN UTAH Ashley Regional Medical Center, Vernal Blue Mountain Hospital, Blanding Castleview Hospital, Price Heber Valley Medical Center, Heber City Kane County Hospital, Kanab Moab Regional Hospital, Moab Park City Medical Center, Park City San Juan Hospital, Monticello Uintah Basin Medical Center, Roosevelt

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