2014 North Sanpete School District

Transcription

1 2014 North Sanpete School District

2

3 Administered by Educators Mutual Insurance Association EMI Health Customer Service or Self Funded Employee Medical Benefit Plan All services are subject to the EMI Health Table of Allowances. When using a Non-participating Provider, the Covered Person is responsible for all fees in excess of the Table of Allowances. EMIA Pool Care Plus September 01, August 31, 2015 Participating Non-Participating PHD0 Provider Option Provider Option GENERAL INFORMATION Preexisting Condition Window Period Preexisting Condition Waiting Period Benefit Accumulator Dependent Age Limit YOU PAY None None Contract Year 26 Coinsurance Maximum (Per Person/Family Per Year) $2,500 / $5,000 $4,000 / $8,000 Medical Deductible (Per Person/Family Per Year) Please note $2,500 / $5,000 $2,750 / $5,500 Non-Preauthorization Patient Penalty Not Applicable 50% Reduction in Benefits Non-Preauthorization Provider Sanction 50% Reduction in Payment Not Applicable PRESCRIPTION DRUG BENEFITS (If brand is purchased when generic is available, member pays the copay plus the difference between the generic and the brand price) YOU PAY Participating Pharmacy (30 day supply) Generic - Covered 100% Preferred - Covered 100% Non-Preferred - Covered 100% Non-Participating Pharmacy Mail Order (90 day supply) Not Covered Generic - Covered 100% Preferred - Covered 100% Non-Preferred - Covered 100% PREVENTIVE SERVICES YOU PAY Routine Physical Exam (1 visit per Year) Covered 100% Not Covered Routine Gynecological Exam (1 visit per Year) Covered 100% Not Covered Family History Exam (1 visit per Year) Covered 100% Not Covered Routine Pap Smear & Mammogram (1 per Year) Covered 100% Not Covered Routine Well-Baby Exams Covered 100% Not Covered Covered Immunizations Covered 100% Not Covered Routine Vision Exam (1 visit per Year) Covered 100% Not Covered Routine Hearing Exam (1 visit per Year) Covered 100% Not Covered PHYSICIAN & PROFESSIONAL SERVICES YOU PAY Physician Office Visits (primary care) Covered 100% 40% Physician Office Visits (secondary care) Covered 100% 40% Physician Office Visits (after hours) Covered 100% 40% Physician Visits (Inpatient) Covered 100% 40% Physician Visits (Outpatient) Covered 100% 40% Major Diagnostic Test, CT Scan, MRI, NMR (office) Covered 100% 40% Minor Diagnostic Test, X-ray, Lab (office) Covered 100% 40% Minor Diagnostic Test, X-ray, Lab (Inpatient) Covered 100% 40% Minor Diagnostic Test, X-ray, Lab (Outpatient) Covered 100% 40% Radiology/Pathology (office) Covered 100% 40% Radiology/Pathology (Inpatient) Covered 100% 40% Radiology/Pathology (Outpatient) Covered 100% 40% Injections (office) Covered 100% 40% Surgery (office) Covered 100% 40% Surgery (Inpatient) Covered 100% 40% Surgery (Outpatient) Covered 100% 40% Anesthesiology (office) Covered 100% 40% Anesthesiology (Inpatient) Covered 100% 40% Anesthesiology (Outpatient) Covered 100% 40% Routine Prenatal & Delivery (Dependent maternity included) Covered 100% 40% Home Health Care (in lieu of Hospital) (for supplies, see Medical Supplies and Equipment) Covered 100% 40% Rehabilitation Therapy (Outpatient physical, speech, occupational, cardiac, or pulmonary - 20 visits per Year) Covered 100% 40% Chiropractic Therapy (20 visits per Year) Covered 100% 40% Allergy Testing Covered 100% 40%

4 EMIA Pool Care Plus September 01, August 31, 2015 Participating Non-Participating PHD0 Provider Option Provider Option Allergy Treatment/Serum Covered 100% 40% DENTAL BENEFITS YOU PAY Impacted Teeth/Cysts/Tumors Covered 100% 40% HOSPITAL/FACILITY BENEFITS YOU PAY (Physician & Professional Services are not included in this section.) Medical/Surgical/Maternity/Intensive Care (semi-private room) Covered 100% 40% Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) Covered 100% 40% Skilled Nursing Facility (60 days per Year) (Admission must be within 5 days of discharge from Hospital Confinement) Covered 100% 40% Medical/Surgical Care (Outpatient) Covered 100% 40% Emergency Room (ER) Covered 100% Covered 100% Major Diagnostic Test, CT Scan, MRI, NMR (Outpatient) Covered 100% 40% Minor Diagnostic Test, X-ray, Lab (Inpatient) Covered 100% 40% Minor Diagnostic Test, X-ray, Lab (Outpatient) Covered 100% 40% Newborn Covered 100% 40% InstaCare/Urgent Care Clinic Covered 100% 40% Eligible Preventive Services Covered 100% Not Covered REHABILITATION THERAPY BENEFIT YOU PAY Inpatient physical, speech, occupational, cardiac, or pulmonary (40 days per person per Year) Covered 100% 40% ACCIDENT AND LIFE THREATENING CONDITION Medical/Surgical Physician/Facility/ER YOU PAY Covered as any other condition Ambulance Land/Air (Accident & Life-threatening) Covered 100% Orthodontic Injury Treatment Covered 100% Covered as a Participating Benefit Dental Injury Treatment Covered 100% TRANSPLANT BENEFIT Heart, Liver, Pancreas, Bone Marrow, Cornea, Lung, Kidney YOU PAY Covered as any other condition Not Covered MEDICAL SUPPLIES & EQUIPMENT Diabetic Testing Supplies (90 day supply) YOU PAY Covered 100% 40% Medical Supplies Covered 100% 40% Medical Supplies (office) Covered 100% 40% Durable Medical Equipment Covered 100% 40% Orthotic Supplies Not Covered Not Covered Growth Hormone Not Covered Not Covered MENTAL HEALTH & DRUG/ALCOHOL TREATMENT Inpatient Facility Semi-private Room (15 days per Year) YOU PAY Covered 100% Not Covered Inpatient Facility Ancillary (15 days per Year) Covered 100% Not Covered Inpatient Facility Physician Visits (15 visits per Year, 1 visit per day) Covered 100% Not Covered Physician Office Visits (15 visits per Year, 1 visit per day) Psychologist / LCSW / APRN / Psychiatrist Covered 100% Not Covered ADDITIONAL BENEFITS YOU PAY Adoption Indemnity Benefit The Plan pays a maximum of $4,000 towards adoption expenses. TMJ Syndrome Not Covered Not Covered Orthognathic/Mandibular Osteotomy Not Covered Not Covered Total Parenteral Nutrition (TPN) Covered 100% Not Covered Primary Infertility Not Covered Not Covered Reduction Mammoplasty Covered 100% Not Covered PLEASE NOTE: This is a summary only and does not guarantee benefits. All benefits are subject to the terms, limitations, and exclusions set forth in the Plan document and in the Summary Plan Description (SPD)/handbook of the Plan. Any discrepancies between this summary, the SPD/handbook, and the Plan document are resolved in favor of the Plan document. For more information, including Preauthorization, refer to the SPD/ handbook or the Plan document, or contact EMI Health Customer Service Department. Services designated are subject to first dollar Medical Deductible Services designated * do not accumulate toward the applicable Coinsurance Maximum.

5 North Sanpete School District 852 East Arrowhead Lane 220 East 700 South Murray, Utah Mt Pleasant, UT (801) / (800) Fax (801) Group: Plan: Underwritten & Administered by: Plan Type: Effective Date: Benefit Year: Type 1 - Preventive Oral Exams, Cleanings, X-rays, Fluoride Type 2 - Basic Fillings, Oral Surgery Type 3 - Major Crowns, Bridges, Prosthodontics Type 4 - Orthodontics Dependent children up to age (26) Adults Orthodontic Discount (All Members) Endodontics Periodontics Sealants Space Maintainers Specialists Waiting periods Type 2 - Basic Type 3 - Major Type 4 - Orthodontics Deductible Per Person Family Max Deductible Applies To Annual Maximum Per Person Orthodontic Lifetime Maximum Network / Reimbursement Schedule Monthly Rates Employee Two-Party Family North Sanpete School District - (Plan #464) Premier PPO Educators Mutual Insurance Association Voluntary / Fully Insured 9/1/2014 Contract In-Network 80% 80% 50% 50% after $250 Deductible No Coverage 25% Discount Type 2 - Basic Type 2 - Basic Type 3 - Major Type 2 - Basic Paid same as General Dentists $0.00 $0.00 N / A Premier None $1, $1, $39.80 $71.70 $ Out-of-Network 80% 80% 50% 50% after $250 Deductible No Coverage No Discount Type 2 - Basic Type 2 - Basic Type 3 - Major Type 2 - Basic Paid same as General Dentists Failure to enroll at first opportunity results in a 12 month waiting period. $0.00 $0.00 N / A Premier Provisions / Limitations / Exclusions Exams (including Periodontal), Cleanings and Fluoride 2 per year Fluoride Any age Sealants Dependent children only Space Maintainers Up to age 17 Bitewing X-Rays 2 per year Periapical X-Rays Covered in Type 1 Panoramic X-Ray 1 every 3 years Impacted Teeth Anesthesia- (Age 8 and over for the extraction of impacted teeth only) Not Covered (Refer to Medical Plan) Not Covered Anesthesia - (For children age 7 and under, once per year) Covered in Type 3 - Major Implants Covered in Type 3 (Limited to $225) Crowns, Pontics, Abutments, Onlays and Dentures Fillings on the same surface 1 every 5 years per tooth 1 every 18 months Benefits illustrated are in summary only. Refer to your Dental Handbook for a complete description of benefits, limitations and exclusions. All Services are subject to EMI Health Table of Allowances. When using a Non-participating Provider, the insured is responsible for all fees in excess of the Table of Allowances. EM.DTL.PREM.CHT.C

6 North Sanpete School District 852 East Arrowhead Lane 220 East 700 South Murray, Utah Mt Pleasant, UT (801) / (800) Fax (801) Group: Plan: Underwritten & Administered by: Plan Type: Effective Date: Benefit Year: Type 1 - Preventive Oral Exams, Cleanings, X-rays, Fluoride Type 2 - Basic Fillings, Oral Surgery Type 3 - Major Crowns, Bridges, Prosthodontics Type 4 - Orthodontics Dependent children up to age (19) Adults Orthodontic Discount (All Members) Endodontics Periodontics Sealants Space Maintainers Specialists Waiting periods Type 2 - Basic Type 3 - Major Type 4 - Orthodontics Deductible Per Person Family Max Deductible Applies To Annual Maximum Per Person Orthodontic Lifetime Maximum Network / Reimbursement Schedule Monthly Rates Employee Two-Party Family North Sanpete School District - (Plan #464) Premier Co-Pay Educators Mutual Insurance Association Voluntary / Fully Insured 9/1/2014 Contract In-Network 100% See Co-Pay Schedule See Co-Pay Schedule No Coverage No Coverage 25% Discount Type 3 - See Co-Pay Schedule Type 3 - See Co-Pay Schedule Type 2 - See Co-Pay Schedule Type 2 - See Co-Pay Schedule Paid same as General Dentists $0.00 $0.00 N / A Premier None None N / A $1, N / A $19.90 $38.50 $79.40 Out-of-Network See Claim Payment Schedule See Claim Payment Schedule See Claim Payment Schedule No Coverage No Coverage No Coverage See Claim Payment Schedule See Claim Payment Schedule See Claim Payment Schedule See Claim Payment Schedule See Claim Payment Schedule $0.00 $0.00 N/A Premier Provisions / Limitations / Exclusions Exams (including Periodontal), Cleanings and Fluoride 2 per year Fluoride Dependent children only Sealants Up to age 17 Space Maintainers Up to age 17 Bitewing X-Rays 2 per year Periapical X-Rays Covered in Type 1 Panoramic X-Ray 1 every 3 years Impacted Teeth Covered in Type 2 - Basic Anesthesia- (Age 8 and over for the extraction of impacted teeth only) Covered in Type 3 - Major Anesthesia - (For children age 7 and under, once per year) Covered in Type 3 - Major Implants Not Covered Crowns, Pontics, Abutments, Onlays and Dentures 1 every 5 years per tooth Fillings on the same surface 1 every 18 months Benefits illustrated are in summary only. Refer to your Dental Handbook for a complete description of benefits, limitations and exclusions. All Services are subject to EMI Health Table of Allowances. When using a Non-participating Provider, the insured is responsible for all fees in excess of the Table of Allowances. Co-Pays are subject to change January 1st of each year. EHC.DTL.COPAY.CHT.C

7 852 EAST ARROWHEAD LANE MURRAY, UT CORPORATE (801) TOLL FREE (800) EMIHealth.com Premier Co-Pay Plan 2014 Sample Co-Pay / Claim Payment Schedule Code Code Name In-Network Member Co-Pay Out-of-Network Claim Payment D0120 Periodic oral evaluation 0 25 D0140 Limited oral evaluation - problem focused 0 35 D0150 Comprehensive oral evaluation - new or established patient 0 34 D0210 Intraoral - complete series (including bitewings) 0 53 D0220 Intraoral - periapical first film 0 13 D0230 Intraoral - periapical each additional film 0 11 D0270 Bitewing - single film 0 12 D0272 Bitewings - two films 0 22 D0274 Bitewings - four films 0 28 D0330 Panoramic film 0 50 D1110 Prophylaxis - adult 0 42 D1120 Prophylaxis - child 0 29 D1208 Topical Application Of Fluoride 0 14 D1351 Sealant - per tooth 14 7 D2140 Amalgam - one surface, primary or permanent D2150 Amalgam - two surfaces, primary or permanent D2160 Amalgam - three surfaces, primary or permanent D2161 Amalgam - four or more surfaces, primary or permanent D2330 Resin-based composite - one surface, anterior D2331 Resin-based composite - two surfaces, anterior D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) D2391 Resin-based composite - one surface, posterior D2392 Resin-based composite - two surfaces, posterior D2393 Resin-based composite - three surfaces, posterior D2394 Resin-based composite - four or more surfaces, posterior D2740 Crown - porcelain/ceramic substrate D2750 Crown - porcelain fused to high noble metal D2751 Crown - porcelain fused to predominantly base metal D2752 Crown - porcelain fused to noble metal D2920 Recement crown 35 0 D2950 Core buildup, including any pins D2954 Prefabricated post and core in addition to crown D3120 Pulp cap - indirect (excluding final restoration) 25 0 D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament 60 0 D3310 Anterior (excluding final restoration) D3320 Bicuspid (excluding final restoration) D3330 Molar (excluding final restoration) D4341 Periodontal scaling and root planing, four or more contiguous teeth or bounded teeth spaces per quadrant D4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis D4381 Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report 20% Disc 0 D4910 Periodontal maintenance D6240 Pontic - porcelain fused to high noble metal D6750 Crown - porcelain fused to high noble metal D7111 Coronal remnants - deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth D7230 Removal of impacted tooth - partially bony D7240 Removal of impacted tooth - completely bony D7810-D7899 Unspecified TMD therapy, by report 20% Disc 0 D8010-D8999 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) 25% Disc 0 D9110 Palliative (emergency) treatment of dental paid - minor procedure 41 0 D9220 Deep sedation/general anesthesia - first 30 minutes D9230 Analgesia, anxiolysis, inhalation of nitrous oxide 20 0 Underwritten or Administered by: Educators Health Plans Life, Accident, and Health or Educators Mutual Insurance Association Benefits illustrated are in summary only. Refer to your Group Certificate booklet for a complete description of benefits, limitations and exclusions. Co-Pays are subject to change January 1st of each year.

8 MR TEST 852 E ARROWHEAD LANE MURRAY, UT Dear Insured: Welcome to EMI Health. We are pleased to provide you with your Medical Identification and Prescription Drug Card. EMI Health has contracted with Medco Health to provide your prescription services program. Be sure to show your card to the pharmacist each time you purchase a prescription. You should also show your card to your medical provider each time you receive services. Please note all items of information on your card. If you have any questions or concerns after detaching your card from the bottom of this letter, please call EMI Health Enrollment Department at or toll free at The reverse side of your card lists telephone numbers and other information pertaining to your insurance plans. If your pharmacy does not currently participate with Medco Health, or if you have questions regarding your pharmacy or prescription drug benefits, please call toll free Sincerely, EMI Health RXD.EMIA N.COMBO.222E015/E RDCP0A00EMIA Detach Cards Here

9 Understanding your EMI Health Medical ID Card UTAH Your EMI Health ID card contains a lot of useful information for you and your provider. It is important that you present your ID card each time you receive services. A B C D EMI Health is your insurance carrier. The employee's name is listed on the ID card. Covered dependents are not listed. Your unique member number is required in order to verify coverage, determine benefits, and pay claims. This is the name of your medical plan and also indicates your participating provider network. To verify a provider's status, visit emihealth.com or call A B E Member Member: John Q. Public Member ID: Employer: EMI Health Medical Plan D Plan 1 - Care Plus Urgent Care Copay: $35 Office Copay: $20 / $35 Coinsurance Max: $2,000 / $4,000 Deductible (in-network: $500 / $1,000 Medical Claims Submission EMI Health 852 East Arrowhead Lane, Murray, Utah Card Front C Medical Identification and Prescription Drug Card Dental Plan F Plan Name: Choice Dental Claims Submission EMI Health 852 East Arrowhead Lane Murray, Utah Pharmacy Plan RxBIN: RxGRP: EMI ARXD Copays: Retail: (30 day) $10 / $35 / $75 Mail Order: (90 day) $25 / $88 / $188 G H E F G H These are your basic copay / coinsurance amounts when you visit a participating provider. For more detailed benefits information, see your Summary of Benefits and member handbook. If you have dental coverage with EMI Health, the name of your dental plan will appear here. This also indicates your dental participating provider network. To verify a provider's status, visit emihealth.com or call Express Scripts is your Pharmacy Benefits Manager. These are your basic copay / coinsurance amounts when you use a participating pharmacy. A B For preauthorization or other customer service inquiries, contact EMI Health at the numbers listed. When travelling outside of Utah, you can save money by using this national medical provider network. Not all plans have participating provider benefits outside of Utah. To confirm your benefits, contact customer service at A B C Customer Service To confirm eligibility, verify benefits or check the status of a claim, call our customer service at or or visit our website at Medical Affiliated Networks Card Back Preathorizations and Disclosures This card does not guarantee coverage. Confirm eligibility and benefit information. Members must preathorize applicable non-panel services. Failure to comply may result in reduction of benefits. Preathorization: or Emergency admissions require authorizations within 24 hours. These palns are underwritten by Educators Health Plans, Life, Accident, and Health, Inc. Dental Affiliated Networks Advantage Outside of Utah Premier Outside of Utah C When travelling outside of Utah, you can save money by using this national dental provider network. Not all plans have participating provider benefits outside of Utah. To confirm your benefits, contact customer service at emihealth.com 852 EAST ARROWHEAD LANE, MURRAY, UTAH TOLL FREE CORPORATE FAX

10 LAWRENCE R. BECK 598 N BROOK AVE TOOELE, UT Understanding your EOBs 10 THIS IS NOT A BILL This is an explanation of how your claim was processed by EMI Health. If you have questions about payments, contact your provider. DATE DESCRIPTION OF SERVICES BILLED CHARGES ELIGIBLE CHARGES PATIENT LAWRENCE R. BECK SUBSCRIBER LAWRENCE R. BECK SUBSCRIBER# PROVIDER OF SERVICE Landon Rockwell CLAIM# DATE PROCESSED 06/05/2012 EMPLOYER GROUP UTA/ATU Bargaining Unit DATE(S) OF SERVICE From: 05/01/2012 To: 05/01/2012 PLAN YEAR From: 5/01/2012 To 4/30/2013 OTHER INS PLAN PAID DEDUCTIBLE COPAY AMOUNT COINS ADJUSTED / NOT COVERED DENIED REASON CODE 05/01/12 Prosthodontic Other Adjustments PLAN YEAR ACCRUALS PARTICIPATING NON PARTICIPATING PATIENT FAMILY PATIENT FAMILY MEDICAL DEDUCTIBLE TO DATE MEDICAL OUT OF POCKET MAXIMUM TO DATE DENTAL DEDUCTIBLE TO DATE DENTAL ANNUAL MAXIMUM TO DATE THIS AMOUNT WILL NOT REFLECT PAYMENTS YOU HAVE MADE TO THE PROVIDER TOTAL $ MEMBER RESPONSIBILITY 8 THE AMOUNTS LISTED ABOVE ARE SUBJECT TO CHANGE DUE TO CLAIM ADJUSTMENTS AND/OR THE ORDER IN WHICH CLAIMS ARE RECEIVED. EXPLANATION OF CODES 09 - Negotiated discount has been applied 8:00 am to 5:00 pm Monday through Friday for Customer Service and Benefit Inquires please call (801) (Local), (800) (toll free) or (801) (fax). REQUEST AND FREE OF CHARGE, REASONABLE ACCESS TO ALL DOCUMENTS, RECORDS, AND OTHER INFORMATION RELEVANT TO THIS CLAIM. IF AGREEMENT IS NOT REACHED AFTER You EXHAUSTION may have OF THE noticed CLAIMS REVIEW the PROCESS format OUTLINED of your IN YOUR Explanation MEMBER HANDBOOK, of YOU Benefits HAVE THE RIGHT (EOB) TO SUBMIT has THE changed. MATTER TO VOLUNTARY It now BINDING contains ARBITRATION even OR TO more PURSUE CIVIL ACTION. useful IF YOU information. ARE COVERED BY MORE Here THAN are ONE HEALTH some PLAN, key YOU features SHOULD FILE ALL you YOUR should CLAIMS WITH understand EACH PLAN. when reading your EOB: CALL US OR VISIT AND CLICK ON THE MEDICARE PART D TAB FOR MORE INFORMATION. 1. Billed Charges: The charges billed by your provider for the services you received. IN ACCORDANCE WITH THE PROVISIONS OF YOUR PLAN, YOU MAY APPEAL FOR RECONSIDERATION OF ANY DENIED PORTION OF THIS CLAIM BY WRITING TO THE ADMINISTRATION OFFICE 2. Eligible (ADDRESS ABOVE). Charges: YOU SHOULD The STATE amount THE REASON established YOU BELIEVE YOUR by EMI CLAIM SHOULD Health BE as PAID, the ATTACHING allowable ANY DOCUMENTATION payment TO for SUPPORT covered YOUR services APPEAL. THE (Table ADMINISTRATOR of Allowance WILL CONSIDER AND RESPOND TO YOUR APPEAL WITHIN THE TIME REQUIRED BY YOUR PLAN. YOU SHOULD REVIEW YOUR PLAN SUMMARY FOR SPECIFIC DIRECTIONS ON HOW AND WHEN AN or APPEAL TOA). MUST The BE FILED. TOA is used for all providers. Participating providers have agreed not to bill you for charges exceeding this amount. If you use nonparticipating providers, you will be responsible for amounts exceeding the TOA. Non-covered services will have $0.00 in this column. 3. Plan Paid: The amount EMI Health paid for this service. BENEFITS DETERMINATION ANY REQUEST FOR A REVIEW OF THIS CLAIM MUST BE RECEIVED BY EMI HEALTH WITHIN 180 DAYS OF THE DATE OF THIS EXPLANATION OF BENEFITS. YOU ARE ENTITLED TO RECEIVE, UPON EMI HEALTH NOW OFFERS A FULL SELECTION OF MEDIGAP & MEDICARE PRESCRIPTION DRUG PLANS. READ THIS CAREFULLY - THIS IS YOUR NOTICE OF PAYMENT OR NONPAYMENT OF CLAIMS. 4. Deductible: The amount applied to your deductible (the amount you pay for eligible charges in a plan year before your plan pays). 5. Copay Amount: The fixed dollar amount you must pay for this service under your plan. 6. Coins: Short for Coinsurance, the percentage of eligible charges you must pay under your plan. 7. Adjusted/Not Covered: The part of the bill that is not paid by your plan. This figure may include amounts to be adjusted by the provider and amounts you are responsible to pay. See "Member Responsibility" to determine what you owe. 8. Denied Reason Code/Explanation Codes: This code and its corresponding explanation provide you with additional information on how the benefits for this claim were determined. 9. Member Responsibility: The amount you are responsible to pay, including any amounts you may have already paid. For example, if you paid your copay at the time of service, that amount will still be included in this total. 10. Plan Year Accruals: The amount you and your covered family members have accrued towards your deductible and out-of-pocket maximum. This includes only claims EMI Health has processed to date. Any services you have received for which claims have not yet been received, or for which claims have recently been received but not yet processed, will not be included in the accrual amounts. Go paperless. Sign up for a My EMI Health account at emihealth.com and view your EOBs online. Page 1 of 1 EMI.MBS.NEW-EOB emihealth.com

11 Sign Up For Your My EMI Health Account Today We are pleased to offer My EMI Health, an online services system for viewing benefit, eligibility, and claims information. Getting started with My EMI Health is easy and only takes a few minutes. Just go to our website at emihealth.com, click on the blue My EMI Health button, and follow these simple steps: 1. Click on the My EMI Health button at the top of the page. 2. Click on "Sign Up Now." 3. Select "Employee" as the type of user and click "Continue." 4. Enter the information requested to identify yourself, and click "Continue." Please note: Your social security number must be entered in the following for (with no dashes): Your date of birth must be entered in the following format: 01/01/1975. For your security, the password you choose must be at least eight characters, including at least one uppercase letter and one number. That's all there is to it. You can then log in to My EMI Health to manage your medical, dental, and vision plans: View benefit descriptions Check claims status Order ID cards Review eligibility/enrollment status View EOBs EMI.MKTG.AAAAAAAAAAAAAA emihealth.com 852 EAST ARROWHEAD LANE, MURRAY, UTAH TOLL FREE CORPORATE FAX

12 My EMI Health As a member of EMI Health, you have access to the following secure online services. My EMI Health Manage your medical, dental, vision, and disability plans: View benefit descriptions Review eligibility/enrollment status Check claims status View Explanations of Benefits (EOBs) for claims starting [date] Order ID cards Express Scripts Manage your prescription benefits: Refill prescriptions Check order status Price medications Locate participating pharmacies Wellness Account Manage your Wellness Account: Take a Health Risk Assessment Sign up for health coaching Read Hope Health newsletter Your employer group must participate in EMI Health's Wellness Program in order to access these services. EMI.MKTG.AAAAAAAAAAAAAA emihealth.com 852 EAST ARROWHEAD LANE, MURRAY, UTAH TOLL FREE CORPORATE FAX

13 Finding Participating Providers Using participating providers is an important part of ensuring that you make the most of your health plan benefits. You can confirm that your provider is part of the EMI Health network, or locate a new participating provider, online at emihealth.com: 1. Click on the "Provider Search" link on the left-hand side of the page. 2. Select the type of network (medical, dental, or vision). 3. Select your plan (as identified on your ID card) and your state. 4. To narrow your search, select one or more of the additional criteria listed. 5. Click "Search." Not all plans have participating provider benefits outside of your state of residence. To confirm your benefits, or if you have any questions, please contact EMI Health's customer service department toll free at EMI.MKTG.AAAAAAAAAAAAAA emihealth.com 852 EAST ARROWHEAD LANE, MURRAY, UTAH TOLL FREE CORPORATE FAX

14 Preventive Care Expanded Preventive Care Services Receiving appropriate preventive care is an important part of protecting your health and detecting problems at an early stage when they are easier to treat. The Affordable Care Act provides for specific preventive services to be covered 100 percent when received by participating providers. EMI Health plans provide 100-percent coverage for preventive services that are rated A or B in the current recommendations of the US Preventive Services Task Force. It is important to note that some services can be done for preventive or diagnostic reasons. Preventive services are those that are provided when there are no symptoms or diagnosed medical conditions. For services to be covered as preventive, your doctor must bill claims with preventive codes. If a preventive service identifies a condition that needs further testing or treatment, regular copayments, coinsurance, or deductibles may apply. Here is just a sample of some preventive services that are covered with no patient cost sharing (deductible, copayment, or coinsurance): Routine physical exam Routine vision exam Routine hearing exam Routine gynecological exam Routine Pap smear Screening mammogram Screening colonoscopy FDA-approved contraception In addition, immunizations recommended by the Advisory Committee on Immunizations Practices of the Center for Disease Controls and Prevention (CDC) will be covered 100 percent if received from a participating provider. As of January 2013, those recommendations are as follows: VACCINE Hepatitis B Rotavirus Diphtheria, Tetanus, Pertussis Haemophilus Influenzae Type b Inactivated Poliovirus Measles, Mumps, Rubella Varicella Pneumococcal Influenza Hepatitis A Meningococcal Human Papillomavirus Birth mo mo mo mo mo mo mo mo years years years years years HepB HepB HepB HepB Catch Up RV RV RV DTaP DTaP DTaP DTaP DTaP DTaP DTaP Catch Up Hib Hib Hib Hib IPV IPV IPV IPV Poliovirus Catch Up MMR MMR MMR Catch Up Varicella Varicella Varicella Catch Up PCV PCV PCV HepA (2 Doses) Influenza (Yearly) HepA Series MCV4 VACCINE Years Years Years Years 65 Years PCV Diphtheria, Tetanus, Pertussis (Td/Tdap) Substitute one-time dose of Tdap for Td booster; then boost with Td every 10 years Td booster every 10 years Measles, Mumps, Rubella 1 or 2 doses 1 doses Varicella 2 doses Zoster 1 dose Pneumococcal 1 or 2 doses 1 dose Influenza 1 dose annually Hepatitis A 2 doses Hepatitis B 3 doses Meningococcal 1 or more dose Human Papillomavirus 3 doses PPSV HPV MCV4 Catch Up HPV Catch Up EMI.MKTG.PREVENTIVE You can find the full list of preventive services at The list is subject to change based on federal guidelines. This information does not apply to grandfathered plans. Please see your summary of benefits and member handbook for the details of your specific plan. emihealth.com 852 EAST ARROWHEAD LANE, MURRAY, UTAH TOLL FREE CORPORATE FAX

15 EMI Health offers a unique opportunity to save you time and money. EMI TeleMed provides nationwide access to a doctor 24 hours a day, 7 days a week, 365 days a year! How does EMI TeleMed work? 1. Patient calls Medical assistant collects patient information. 3. Doctor calls for consultation. 4. Doctor calls in prescription if necessary. With an average waiting time of 20 minutes for a return call from the doctor, you can't afford to pass on this offer. Here's how EMI TeleMed saves: EMI TeleMed = $10.00 at time of service Common office visit = $ Common urgent care visit = $ Common emergency room visit = $ For only $10 per call, you can save more than 60% on office visits, more than 70% on urgent care visits, or more than 90% compared to going to an emergency room. Common conditions treated through the EMI TeleMed network: Acid reflux Headache Acne Heartburn Allergies Hemorrhoids Asthma Joint pain Bladder infection Nausea Bronchitis Pink eye Cold Rashes Constipation Shingles Cough Sinus pain Diarrhea Sore throat Ear pain Stomach virus Flu Thyroid conditions Fever Urinary tract infections Gout Yeast infections network powered by EMI.MKTG.GRP-TELEMED Once you have received your TeleMed ID card please visit for additional information and services. emihealth.com 852 EAST ARROWHEAD LANE, MURRAY, UTAH TOLL FREE CORPORATE FAX

16 Change Healthcare (CHC) At EMI Health, we understand that to remain successful in today s increasingly competitive environment, you must be able to attract and retain the best talent, provide high quality healthcare while lowering costs, and increase employee engagement and satisfaction. This is why we ve joined forces with Change Healthcare, the market leader in consumer engagement and cost transparency, to bring you several new tools designed to support your long-term success. EMI Health in partnership with CHC will provide you and your employees access to: Cost Lookup Proac ve Alerts Healthcare University Provides consumers the ability to iden fy the best priced op on for a combina on of nearly 3,000 medical, pharmacy, dental and vision services. Proac ve, personalized alerts that focus on popula on health and user savings opportuni es to drive engagement. Gamified benefits educa on pla orm that educates members on topics ranging from healthcare basics to consumerism. Change Healthcare s approach delivers market-leading sustained engagement rates and quantifiable savings. EMI Health is excited to bring you these new tools. We think you re going to like what you see. Delivers personalized solutions that are relevant to the individual; Educates on how to be a better healthcare consumer; Creates awareness of resources available to help; Reaches out proactively, again and again, with savings opportunities; and Encourages sustained engagement to drive long-term behavior change, transforming passive healthcare users into proactive healthcare consumers.

17 Beaver County Beaver Valley Hospital 1109 North 100 West Beaver, UT (435) Milford Valley Memorial Hospital 451 North Main Street Milford, UT (435) Box Elder County Bear River Valley Hospitall 905 N W Tremonton, UT (435) Cache County Logan Regional Hospital 500 E N Logan, UT (435) Carbon County Castleview Hospital 300 N Hospital Dr Price, UT (435) Davis County Davis Hospital and Medical Center 1600 W Antelope Dr Layton, UT (801) Duchesne County Uintah Basin Medical Center 250 W 3000 N Roosevelt, UT (435) Garfield County Garfield Memorial Hospital 200 N 400 East St Panguitch,, UT (435) Grand County Moab Regional Hospitall 450 Williams Way Moab, UT (435) Iron County Valley View Medical Center 1303 N Main St Cedar City, UT (435) Juab County Central Valley Medical Center 48 W 1500 N Nephi, UT (435) Kane County Kane County Hospital 355 N Main St Kanab, UT (435) Millard County Delta Community Medical Center 126 White Sage Ave Delta, UT (435) Fillmore Community Medical Center 674 S Highway 99 Fillmore, UT (435) Salt Lake County Alta View Hospital 9660 S 1300 E Sandy, UT (801) Intermountain Medical Center 5121 Cottonwood St Murray, UT (801) John A Moran Eye Center 65 Mario Capecchi Dr Salt Lake City, UT Salt Lake County Jon and Karen Huntsman Cancer Cntr 5121 Cottonwood St Murray, UT (801) LDS Hospital 8th Ave and C St Salt Lake City, UT (801) Primary Childrens Medical Center 100 Mario Capecchi Dr Salt Lake City, UT (801) Primary Childrens Rehab Unit 100 Mario Capecchi Dr Salt Lake City, UT (801) TOSH The Orthopedic Specialty Hospital 5848 South Fashion Blvd Murray, UT (801) U of U Hospital Burn Center 50 N Medical Dr Salt Lake City, UT (801) Riverton Hospital 3741 W S Riverton, UT (801) San Juan County Blue Mountain Hospital 802 S 200 W Ste A Blanding, UT (435) San Juan Hospital 380 West 100 North Monticello, UT (435)

18 Sanpetee County Gunnison Valley Hospital 45 East 100 North St Gunnison, UT (435) Sanpete Valley Hospital 1100 S Medical Dr Mount Pleasant, UT (435) Sevier County Sevier Valley Medical Center 1000 N Main St Richfield, UT (435) Summit County Park City Medical Center 900 Round Valley Dr Park City, UT (435) Tooele County Mountain West Medical Center 2055 N Main St Tooele, UT (435) Uintah County Ashley Valley Medical Center 75 North 200 West Vernal, UT (435) Utah County American Fork Hospital 170 N 1100 E American Fork, UT (801) Orem Community Hospital 331 N 400 W Orem, UT (801) Utah Valley Regional Medical Center 1034 N 500 W Provo, UT (801) Utah Valley Regional Rehab Unit 1034 N 500 W Provo, UT (801) Wasatch County Heber Valley Medical Center 1485 S Highway 40 Heber City, UT (435) Washington County Dixie Regional Medical Center 1380 E Medical Center Dr St George, UT (435) Dixie Regional Psychiatricc Unit 1380 E Medical Center Dr St George, UT (435) Dixie Regional Rehabilition Unit 1380 E Medical Center Dr St George, UT (435) Weber County McKay Dee Hospital 4401 Harrison Blvd Ogden, UT (801) McKay Dee Hospital Rehab Unit 4401 Harrison Blvd Ogden, UT (801) McKay Dee Hospital Rehab Unit 4401 Harrison Blvd Ogden, UT (801)

19 Cache County Logan InstaCare 412 North 200 East Logan, Utah M Sun 8AM 8PM Davis County Layton InstaCare 2075 University Park Blvd. (1200 West) Layton, Utah M F 8:30AM 9PM Sat Sun 8:30AM 5PM Bountiful InstaCare 390 North Main St.. Bountiful, Utah M Sun 9AM 9PM Syracuse InstaCare 745 South 2000 West Syracuse,Utah M F 9AM 9PM Sat Sun 9AM 3PM Iron County Cedar City InstaCare 962 Sage Drive Cedar City, Utah M Sat 9AM 9PM Salt Lake County Holladay InstaCare 6272 S. Highland Drive Murray, Utah M Sun 9AM 9PM Memorial InstaCare 2000 South 900 East Salt Lake City, Utah M Sun 9AM 9PM Salt Lake County Murray InstaCare 196 East Winchester St Murray, Utah M Sun 9AM 9PM Riverton Southridge InstaCare 3723 West South #1500 Riverton, Utah M Sun 8AM 10PM Salt Lake InstaCare 389 South 9000 East Salt Lake City, Utah M Sun 9AM 9PM Sandy InstaCare 9493 South 700 East Sandy, Utah M Sun 9AM 9PM Taylorsville InstaCare 3845 West 4700 South Taylorsville, Utah M Sun 8AM 10PM West Jordan InstaCare 2655 West 9000 South West Jordan, Utah M Sun 8AM 10PM Tooele County Tooele InstaCare 777 N Main St. Tooele, Utah M Sun 9AM 9PM Utah County Washington County Highland InstaCare North Alpine Hwy Highland, Utah M F 8AM 8PM Sat 9AM 5PM InstaCare North Orem 1975 North State Street Orem, Utah M Sun 8AM 10PM Provo InstaCare 1134 North 500 West, #102 Provo, Utah M Sun 9AM 9PM Saratogaa InstaCare 354 West State Rd 73 Saratoga Springs, Utah M Sat 8AM 8PM Springville InstaCare 762 West 400 South Springville, Utah M Sun 8AM 8PM Hurricane Valley InstaCare 75 North 2260 West Hurricane, Utah M Sat 9AM 9PM St. George Sunset InstaCare 1739 West Sunset Blvd St. George, Utah M Sat 9AM 9PM St.George River Road InstaCare 577 South River Road St. George, Utah M Sun 9AM 9PM

20 Weber County North Ogden InstaCare 2400 North Washington Blvd North Ogden, Utah M Sat 9AM 9PM Sun 9AM 5PM Roy Herefordshire InstaCare 1915 West 5950 South Roy, Utah M Fri 8AM 9PM Sat 9AM 9PMM Sun 1PM 5PMM South Ogden InstaCare 975 East Chambers St South Ogden, Utah M F 9AM 9PM Sat 9AM 5PM Sun 9AM 1PM Salt Lake County Riverton Southridge KidsCare 3723 West South, #150 Riverton, Utah M F 5PM 10PM Sat Sun 12PM 10PM Salt Lake Memorial KidsCare 2000 South 900 East Salt Lake City, Utah M F 5PM 10PM Sat Sun 12PM 10PM Sandy Mountainview KidsCare 9720 South 1300 East, Suite E100 Sandy, Utah M F 5PM 10PM Sat 12PM 5PM Sun 12PM 10PM Salt Lake County Taylorsville KidsCare 3845 West 4700 South Taylorsville, Utah M F 5PM 10PM Sat Sun 8AM 10PM West Jordan KidsCare 2655 West 9000 South West Jordan, Utah M F 5PM 10PM Sat Sun 12PM 5PM Weber County Ogden Northern Utah KidsCare 4403 Harrison Blvd., Suite 4875 Ogden, Utah M F 5PM 9PMM Sat Sun 10AM 4PM Davis County Bountiful KidsCare 390 North Main St Bountiful, Utah M F 5PM 10PM Sat Sun 12PM 10PMM Layton KidsCare 2075 University Park Blvd. (1200 West) Layton, Utah (801) M F 5PM 9PM

21 EMIA POOL 2014 PRESCRIPTION DRUG AND HOME DELIVERY PHARMACY SERVICE EXCLUSIONS Pharmacy Items Excluded The following items are excluded under the prescription drug and home delivery pharmacy service (mail order) programs, regardless of medical necessity or prescription by a licensed prescriber: 1. Medication received by a Covered Person before coverage under the Plan is effective or after coverage under the Plan ends. 2. Medication that is not Medically Necessary and appropriate. 3. Fertility medication (Primary or Secondary Infertility). 4. Anorexiants. 5. Chemotherapeutic medications, administered by IV or injections. 6. Hemophiliac medications. 7. Medication which is to be taken by, or administered to, an individual, in whole or in part, while He is a patient in a licensed Hospital, rest home, sanitarium, Extended Care Facility, skilled nursing facility, convalescent Hospital, nursing home, or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals. 8. Any prescription refilled in excess of the number of refills specified by the physician, or any refill dispensed after one year from the physician s original order. 9. Any drug exceeding the number of days supply or doses eligible in the Plan. 10. Charges for the administration of any drug. 11. Any drugs used for weight loss, and related services, or complications thereof. 12. Progesterone suppositories and related services or complications thereof. 13. Any drug that does not require a prescription except insulin and evidence-based items or services that have in effect a rating of A or B in the current recommendations of the U.S. Preventive Services Task Force. (For guidelines refer to Any over-the-counter drugs even if prescribed by a physician except for evidence-based items or services that have in effect a rating of A or B in the current recommendations of the U.S. Preventive Services Task Force. (For guidelines refer to This exclusion includes but is not limited to, supplements and nutritional substitutes, enteral feedings, amino acids, electrolyte supplements, herbs, and related services. 15. Any drug provided under another provision of the Plan; e.g., Inpatient Hospital use. 16. Any drug purchased for Cosmetic purposes, or complications thereof. 17. Any item specifically limited or excluded in the medical exclusions. (See Medical Plan Exclusions section.) 18. Any drug for erectile dysfunction. 19. Any drug when it has been determined by the clinical consultants of EMI Health that there is over-utilization of drugs or evidence of drug abuse.

22 20. Medication amounts in excess of maximum quantity and/or dosage levels indicated by the drug manufacturer and the FDA. Experimental medications, medications for nonapproved FDA indications, or non-approved indications as determined by EMI Health. 21. Preventive medications including equipment and application of medications, including but not limited to, fluoride, vitamins, minerals, and homeopathic medicine. This exclusion does not include prenatal vitamins prescribed by a physician during pregnancy or those that have in effect a rating of A or B in the current recommendations of the U.S. Preventive Task Force. (For guidelines refer to Unit dose packaging of prescription drug products, including but not limited to, Factor VIII. 23. Non-self-administered Injectables. 24. Any drug when it has been determined that the authorization criteria of EMI Health have not been satisfied. With respect to Injury which is otherwise covered by the Plan, the Plan will not deny benefits otherwise provided for treatment of the Injury if the Injury results from being the victim of an act of domestic violence or a medical condition.

23 EMIA POOL 2014 MEDICAL PLAN EXCLUSIONS Notwithstanding anything else in the Plan to the contrary, the items listed below are not covered by the Plan. The Plan does not pay for the following: 1. Services received by a Covered Person before coverage under the Plan became effective or after coverage under the Plan has terminated. 2. Services not specified as covered. There is no presumption of coverage. 3. Care, supplies, treatment, and/or services that are not payable under the Plan due to application of any Plan maximum or limit, or because the billed charges are in excess of the Maximum Allowable Charge, or are for services not deemed to be reasonable or Medically Necessary and appropriate, based upon the Plan Administrator s determination as set forth by and within the terms of this document. 4. Any Copayments or Deductibles incurred under this Plan, except as they are applied to the Coinsurance Maximum where applicable. 5. Illness or injury caused by the negligent or wrongful act of another, or for which the Covered Person is covered by any workers compensation or similar law; except that the Plan may advance benefits to or on behalf of the Covered Person in such situations, subject to the Plan s right of Subrogation and reimbursement set forth herein, 6. Illness or injury that a Covered Person incurred either (1) while in the service of an employer that was obligated by law to provide workers compensation insurance that would have covered such Illness or injury, or, (2) while in the service of an employer that had elected to exclude workers compensation coverage for such Covered Person, except that the Plan may elect to advance benefits to or on behalf of the Covered Person in either situation, subject to the Plan s right to Subrogation and reimbursement set forth herein. 7. Illness or injury for which the Covered Person is covered by other responsible insurance including, but not limited to, coverage under a government sponsored health plan, underinsured motorist coverage, or uninsured motorist coverage, except as otherwise provided herein. 8. Care, supplies, treatment, and/or services for Injuries resulting from negligence, misfeasance, malfeasance, nonfeasance, or malpractice on the part of any licensed Physician. 9. Care, supplies, treatment, and/or services that are expenses to the extent paid, or which the Covered Person is entitled to have paid or obtain without cost, in accordance with the laws or regulations of any government. 10. Care, supplies, treatment, and/or services of an Injury or Illness not payable by virtue of the Plan s Subrogation, reimbursement, and/or third-party responsibility provisions. 11. Except as otherwise provided by law, charges for Hospital Confinement, services, supplies, or treatment the Covered Person is not legally required to pay. 12. Charges for Hospital Confinement, services, supplies, or treatment received while the Covered Person is incarcerated in a correctional facility.

24 13. Coverage for Illness or injury as a result of war or any act of war, whether declared or undeclared, or caused while performing service in the armed forces of any country. 14. Charges for procedures, supplies, equipment, and services, which are not Medically Necessary and appropriate. 15. Care, supplies, treatment, and/or services that do not restore health, unless specifically mentioned otherwise. 16. Care, treatment, or services provided when there are no symptoms of Illness or injury, or when there is or has been no diagnosis of Illness or injury. 17. Care, treatment, or surgical procedures incurred primarily for convenience, contentment, or other non-therapeutic purposes. 18. Expenses in connection with immunizations, unless otherwise listed in this Plan. 19. Expenses for personal hygiene, convenience, wellness, or preventive care including, but not limited to, buildings, motor vehicles, air conditioners, whirlpool baths, exercise equipment, or other multi-purpose equipment or facilities, related appurtenances, controls, accessories, or modifications thereof. 20. Convenience items in or out of the Hospital such as guest trays, cots, telephone calls, and other services. 21. Expenses for preparing medical reports, itemized bills, or claim forms. 22. Expenses for shipping, handling, postage, sales tax, interest, finance charges, and other administrative charges. 23. Transportation expenses including, but not limited to, mileage reimbursement, airfare, meals, accommodations, and car rental. 24. Ancillary charges made by a medical institution, Hospital, clinic, hospice, nursing home, or similar facility to hold or reserve a room during any temporary leave of absence of the Covered Person, or in anticipation of a Hospital stay. 25. Additional reimbursement based upon the technique, approach, or instruments used in treatment. Payment is based on the standard base-level method of treatment only. 26. Any care, treatment, or expenses for Cosmetic procedures or complications thereof, including Reconstructive or corrective procedures done primarily for Cosmetic purposes. A care, treatment, or procedure is considered Cosmetic when it is primarily intended to improve appearance or correct a deformity without restoring physical bodily function. Psychological factors such as, but not limited to, poor self-image or difficult peer or social relations are not relevant and do not justify a Cosmetic procedure as being Medically Necessary. The reversal of a non-covered Cosmetic procedure is not covered. This exclusion does not apply to Reconstructive Surgery performed or treatment required under the Women s Health and Cancer Rights Act of Care, treatment, services, or surgical procedures rendered for abdominoplasties, diastasis recti abdominous, protruding ears, breast enlargement, or gynecomastia, or for complications thereof. 28. Care, treatment, services, or surgical procedures rendered for reduction mammoplasty, unless the patient meets EMI Health s criteria, a copy of which will be provided upon request. 29. Care, treatment, services, or surgical procedures rendered for blepharoplasty, unless the patient meets EMI Health s criteria, a copy of which will be provided upon request. 30. Health services and associated expenses for the surgical treatment and non-surgical medical treatment of obesity (whether morbid obesity or not) including, but not limited

25 to, weight loss programs, except for evidence-based items or services that have in effect a rating of A or B in the current recommendations of the U.S. Preventive Services Task Force. (For guidelines refer to Expenses in connection with gastric banding, gastric stapling, or digestive bypass, or for complications thereof. 32. Educational or behavioral modification services or counseling including, but not limited to, biofeedback, weight control clinics, stop-smoking clinics, cholesterol counseling, exercise programs, or other types of physical fitness training, except for evidence-based items or services that have in effect a rating of A or B in the current recommendations of the U.S. Preventive Services Task Force. (For guidelines refer to Confinement, education, or training in a nursing home, rest home, or similar establishment, including an institution that is primarily a school or other institution for training, except an Extended Care Facility as provided in this Plan. 34. Expenses in connection with Custodial Care. 35. Charges in connection with institutional care, including residential treatment or programs, which as determined by the Plan, is for the primary purpose of controlling or changing the environment for the individual. 36. Charges for cognitive therapy. 37. Care or treatment of learning disability, mental retardation, or chronic organic brain syndrome, except services required to diagnose any of the above. 38. Treatment or services for marriage counseling and any counseling or psychotherapy for relief of family or marital discord, divorce, preparation for marriage, encounter groups, parental counseling, treatment for situational disturbances such as financial or environmental problems, or other types of everyday stresses and strains. 39. Expenses for treatment of personality disorders, behavior disorders, or chronic situational reactions; occupational, religious, or other social maladjustment; or non-specific conditions such as acts of impulse including, but not limited to, gambling, pyromania, and kleptomania. 40. Care, treatment, procedures, or services for transsexualism, gender dysphoria, sexual reassignment, psychosexual identity disorder, or psychosexual dysfunction. This exclusion does not apply to the initial assessment and diagnosis of the condition. 41. Care, supplies, treatment, and/or services for any Injury or Illness which is incurred while taking part or attempting to take part in an Act of Aggression or an illegal activity, including but not limited to misdemeanors and felonies. It is not necessary that an arrest occur, criminal charges be filed, or if filed, that a conviction result. Proof beyond a reasonable doubt is not required to be deemed an illegal act. This exclusion does not apply (a) if the Injury resulted from being the victim of an act of domestic violence, or (b) resulted from a medical condition (including both physical and mental health conditions). 42. Care, treatment, or services for any Illness or injury resulting from, or caused by, intoxication or the use of any drug unless such drug is administered or prescribed by a physician and taken in the manner prescribed and unless the patient meets EMI Health s criteria, a copy of which will be provided upon request. 43. Care, treatment, or services, including Custodial Care, for substance abuse or the aftereffects of substance abuse including, but not limited to, alcoholism, narcotism, or use

26 of hallucinogenic drugs or similar substances, except as specifically provided under Mental Health and Drug/Alcohol treatment. 44. Infertility services including, but not limited to, the following: Artificial insemination, sperm washing, sperm banking, and/or storage. Donor costs. Experimental or Investigative treatment. Gamete intrafallopian transfer ( GIFT ). Hamster egg penetration tests. In-vitro fertilization (IVF). Medications for Infertility and ultrasounds associated with Infertility medications therapy. Non-participating Provider or facility services for Infertility. Zygote intrafallopian transfer ( ZIFT ). Surrogate mothers. Secondary Infertility. Expenses in connection with retrieval or collection of semen and/or ovum. 45. The Adoption Indemnity Benefit (see Additional Benefit section) in connection with the adoption of any child over 90 days of age. 46. The reversal of a surgically performed sterilization, subsequent sterilization, or ovulationinducing drugs or injections. 47. Expenses in connection with abortion, except as follows: Where documented by medical evidence that the life of the mother would be endangered if the fetus were carried to term. Where the pregnancy is the result of incest or rape. 48. Care, treatment, or surgical procedures for erectile dysfunction. 49. Care, treatment, or devices to aid in female sexual arousal disorder including, but not limited to, Eros Clitoral Therapy Device. 50. Expenses in connection with a penile prosthesis. 51. All organ Transplant services when rendered by Non-participating Providers. 52. Services for cross matching and/or harvesting organs from live or deceased donors for all non-covered Transplant/Implant services and whenever the organ recipient is not a Covered Person. 53. Repair or replacement of any otherwise covered Implant when rendered by Nonparticipating Providers. 54. Expenses for and in connection with artificial hearts, LVAD, LVAS, and ventricularassist devices. 55. Duplication, replacement, upgrade, improvement, alteration, or repair of existing Durable Medical Equipment, except this exclusion does not apply to the replacement of Durable Medical Equipment other than Durable Medical Equipment that EMI Health has previously paid for under Medical Supplies and Equipment. This includes parts, such as but not limited to, batteries. Replacement of existing Durable Medical Equipment will only be covered if the replacement is Medically Necessary due to normal physical growth of the Covered Person. Expenses related to modifications and/or improvements to home, van, or other vehicle, regardless of medical necessity are excluded. This exclusion does not apply to medical supplies for use with insulin pumps and/or insulin infusion pumps.

27 56. Care, treatment, or surgical procedures in connection with hearing aids, devices, or implants including but not limited to cochlear implantation. This exclusion includes the fitting of such devices. 57. Eyeglasses, contact lenses, or the fitting of eyeglasses or contact lenses, with the exception of one lens per operated eye following eye surgery; for example, an external contact lens or surgically implanted intraocular lens. This exclusion does not apply to contact lenses for Keratoconus diagnosis. 58. Radial keratotomy or lamellar keratectomy, or other eye surgery performed primarily to correct refractive errors. 59. Dental, mouth, and jaw services including, but not limited to, all care, treatment, therapy, surgery, or diagnostic procedures for the following, unless otherwise indicated in the Summary of Benefits chart: Appliances, bite guards, space maintainers, splints Bone resection, bone screws, Implants Crowns or caps, dentures, permanent bridgework Endodontics, nerves within the teeth Full mouth rehabilitation therapy Injection of joints Maxillary and or mandibular osteotomy Orthodontic treatment Orthognathic procedures, upper/lower jaw augmentation or reduction procedures, including problems due to development or altering of vertical dimensions Periodontics, gums alveolar processes Prosthodontic treatment Restorations, including restoration of occlusion Teeth, including nursing bottle syndrome, caries, etc. X-rays Temporomandibular joint disorders (TMJ) Impacted teeth 60. Dental anesthesia. This exclusion does not apply to covered oral surgery, or when treatment is for a Covered Person who is four years old or younger. 61. Services, supplies, or accommodations provided in connection with the following: Routine cutting, removal, or other treatment of corns, calluses, or toenails unless deemed Medically Necessary and appropriate due to infection or a metabolic disease such as diabetes mellitus or a peripheral vascular disease such as arteriosclerosis. Orthopedic shoes that are not attached to a brace. 62. Expenses in connection with speech therapy, unless required as a result of speech defects as a result of Illness or Accident. 63. Expenses for whole blood, or blood derivatives. 64. Care, treatment, or services involving acupuncture, acupressure, dry needling, or hypnosis. 65. Care, treatment, surgical procedures or supplies, or any appliances, aids, devices, or drugs that are illegal, Experimental, or Investigative as defined in the Plan, or for complications thereof.

28 66. Care, treatment, supplies, appliances, aids, devices, or drugs that are 1) not approved by the FDA for the particular medical indication, or 2) are still under investigation, and current peer-reviewed studies or national professional guidelines do not indicate superiority or significant improvement over current, accepted standards of care. 67. Care, treatment, or services including, but not limited to, testing associated with autogenous urine immunization, sublingual provocation, leukocytoxicity, and subcutaneous provocation and neutralizing. 68. Expenses in connection with herbal, holistic, or homeopathic treatment, or for complications thereof. 69. Genetic counseling and testing except prenatal amniocentesis, chorionic villi sampling for high risk pregnancy, and BRCA counseling regarding genetic testing for women at higher risk. 70. Expenses related to a sleep laboratory or facility, except services related to sleep apnea, unless otherwise indicated. This includes, but is not limited to, insomnia. 71. Expenses for any of the following: Ambulance services when the individual could be safely transported by means other than ambulance. Air ambulance services when the Covered Person could be safely transported by ground ambulance or by means other than ambulance. Ambulance services beyond transportation to the nearest facility expected to have appropriate services for the treatment of the injury or Illness involved. Ambulance services for conditions, other than injuries received in an Accident, not deemed Life-threatening. 72. Special duty nursing services, including the following: That ordinarily would be provided by the Hospital staff or its Intensive Care unit. (The Hospital benefit pays for general nursing service by Hospital staff.) Requested by, or for the convenience of, the Covered Person or the Covered Person s family or consisting primarily of bathing, feeding, exercising, housekeeping, moving the Covered Person, giving medication, or acting as a companion or sitter, or when otherwise deemed not to be Medically Necessary and appropriate. Rendered by a private duty nurse, who is an immediate family member (e.g. Spouse, parent). Home Health aides or services. 73. Charges for physician calls in excess of one per physician per day, or for a mid-level provider and the supervising Physician in the same day. 74. Expenses for appointments scheduled but not kept. 75. Expenses for telephone consultations or services delivered remotely via or other telecommunication technologies, except as specifically provided under a telemedicine benefit. 76. Care, treatment, or services rendered by any Provider who ordinarily resides in the same household (e.g. Spouse, parent). 77. Services performed by a Provider type that is not covered by the Plan including, but not limited to, the following: Acupuncturist Registered dietician

29 Doctor of education Clergy Home Health/nurse aid Hygienist Hypnotist Medical assistant Massage therapist Naturopath Vocational nurse Personal fitness trainer/coach 78. All self-administered Injectables. (Refer to Prescription Drug Program. ) This exclusion does not apply to the following: Neupogen (Filgrastim) Epogen, Procrit (Epoetin Alfa) Lupron, Lupron Depot, Lupron Depot-3 month, Lupron Depot-4 month, Lupron Depot-Ped, Lupron Depot-Gyn, Oaklide (Leuprolide Acetate) Neulasta (Pegfilgrastim) Neumega (Oprelvekin) Leukine, Prokine (Saragramostim) 79. All medications that are excluded under the Prescription Drug Program are also excluded under Medical. This exclusion does not apply to the following (under Medical plan): Chemotherapeutic medications. Hemophiliac medications. Otherwise covered medication which is to be taken by, or administered to, an individual, in whole or in part, while He is a patient in a licensed Hospital, rest home, sanitarium, Extended Care Facility, skilled nursing facility, convalescent Hospital, nursing home, or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals. Any otherwise covered drug provided under another provision of the Plan; e.g. Inpatient Hospital use. Unit dose packaging of prescription drug products, including but not limited to, Factor VIII. Medically Necessary and appropriate enteral feeding when administered via nasogastric, gastrotomy, or jejunostomy tube. 80. All services, equipment, and supplies provided or ordered to treat complications of a noncovered Illness, injury, condition, situation, procedure, or treatment. With respect to any Injury which is otherwise covered by the Plan, the plan will not deny benefits otherwise provided for treatment of the Injury if the Injury results from being the victim of an act of domestic violence or a medical condition.

30 The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription-drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate Express Scripts Preferred Drug List PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription-drug benefit programs; check your benefit materials for the specific drugs covered and the copayments for your prescription-drug benefit program. For specific questions about your coverage, please call the phone number printed on your ID card. A ABILIFY, ABILIFY DISCMELT ACANYA ACCU-CHEK LANCETS; FASTCLIX, MULTICLIX, SOFT TOUCH, SOFTCLIX acetaminophen/codeine ACTONEL acyclovir ACZONE ADCIRCA AGGRENOX albuterol alendronate sodium allopurinol ALPHAGAN P 0.1% alprazolam ALREX amiodarone AMITIZA amitriptyline amlodipine amlodipine/benazepril amoxicillin amoxicillin/potassium clavulanate amphetamine salt combo amphetamine salt combo ext-release AMPYRA AMTURNIDE ANALPRAM ADVANCED CREAM KIT ANALPRAM HC 1% CREAM, 2.5% LOTION anastrozole ANDRODERM ANDROGEL antipyrine/benzocaine ARANESP [INJ] arbinoxa ARCAPTA ASACOL HD ASMANEX ASTEPRO ATELVIA atenolol atenolol/chlorthalidone atorvastatin ATRALIN AVELOX AVONEX [INJ] AXIRON AZASITE azathioprine azelastine nasal spray AZILECT azithromycin AZOR B baclofen benazepril benazepril/ hydrochlorothiazide 2014 Express Scripts Holding Company All Rights Reserved BENICAR, BENICAR HCT BENZACLIN PUMP benzonatate BEPREVE BESIVANCE BEYAZ bisoprolol/ hydrochlorothiazide BRILINTA BROMDAY budesonide neb susp bupropion bupropion ext-release (12 hour) bupropion ext-release (24 hour) buspirone butalbital/acetaminophen/ caffeine BUTRANS BYDUREON [INJ] BYETTA [INJ] BYSTOLIC C calcipotriene CANASA carbidopa/levodopa carvedilol cefdinir cefprozil cefuroxime CELEBREX CENESTIN cephalexin CETROTIDE [INJ] chlorthalidone chorionic gonadotropin [INJ] CIALIS CIPRODEX ciprofloxacin ciprofloxacin eye solution citalopram clarithromycin clindamycin hcl clindamycin phosphate clobetasol propionate clomiphene citrate clonazepam clonidine clopidogrel clotrimazole/ betamethasone dipropionate COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COPAXONE [INJ] COREG CR CREON CRESTOR CRINONE cyanocobalamin [INJ] cyclobenzaprine CYMBALTA D DALIRESP DAYTRANA DELZICOL desloratadine desonide DETROL LA dexamethasone diazepam diclofenac sodium delayed-release dicyclomine hcl DIFFERIN 0.3% GEL, 0.1% LOTION digoxin diltiazem ext-release (24 hour) DIOVAN diphenoxylate/atropine divalproex sodium ext-release DIVIGEL donepezil dorzolamide/timolol doxazosin doxepin doxycycline hyclate doxycycline monohydrate DULERA DUREZOL E EFFIENT ELIDEL eliphos ELIQUIS enalapril ENBREL [INJ] ENDOMETRIN ENJUVIA enoxaparin [INJ] EPIDUO EPIPEN, EPIPEN JR [INJ] ergocalciferol erythromycin eye ointment escitalopram estradiol estradiol/norethindrone acetate etodolac EUFLEXXA [INJ] EURAX EVAMIST EVISTA EXELON PATCHES EXFORGE, EXFORGE HCT EXTAVIA [INJ] F famotidine fenofibrate fenofibrate micronized fentanyl citrate FENTORA FINACEA, FINACEA PLUS finasteride fluconazole fluocinonide fluoxetine fluticasone nasal spray FOCALIN XR folic acid FORADIL FORTEO [INJ] FOSRENOL FRAGMIN [INJ] furosemide THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, THIS LIST IS SUBJECT TO CHANGE. You can get more information and updates to this document at our website at G gabapentin GELNIQUE gemfibrozil GENOTROPIN [INJ] gianvi glimepiride glipizide glipizide ext-release GLUCAGEN [INJ] GLUCAGON [INJ] glyburide glyburide/metformin GONAL-F [INJ] GRALISE H HALFLYTELY-BISACODYL HUMALOG [INJ] HUMATROPE [INJ] HUMIRA [INJ] HUMULIN [INJ] hydralazine hydrochlorothiazide hydrocodone/ acetaminophen hydrocodone/ chlorpheniramine polistirex hydrocodone/homatropine hydrocodone/ibuprofen hydrocortisone topical hydromorphone hydroxychloroquine hydroxyzine hcl hydroxyzine pamoate I ibandronate ibuprofen ILEVRO INCIVEK indomethacin INTUNIV INVOKANA irbesartan isosorbide mononitrate ext-release J JANUMET, JANUMET XR JANUVIA JUVISYNC K ketoconazole topical KOMBIGLYZE XR KRISTALOSE L labetalol hcl LAMICTAL ODT lamotrigine lansoprazole delayed-release LANTUS, LANTUS SOLOSTAR [INJ] latanoprost LATUDA LETAIRIS levalbuterol LEVEMIR, LEVEMIR FLEXPEN [INJ] levetiracetam levocetirizine levofloxacin levothyroxine sodium LIALDA LINZESS liothyronine LIPOFEN LIPTRUZET lisinopril lisinopril/ hydrochlorothiazide lithium carbonate LOESTRIN 24 FE, LO LOESTRIN FE lorazepam loryna losartan losartan/ hydrochlorothiazide LOTEMAX lovastatin LOVAZA LUMIGAN LUNESTA LYRICA M MAKENA [INJ] meclizine hcl medroxyprogesterone acetate meloxicam metaxalone metformin metformin ext-release methadone methimazole methocarbamol methotrexate methylphenidate methylphenidate ext-release methylprednisolone metoclopramide hcl metoprolol succinate ext-release metoprolol tartrate metronidazole metronidazole vaginal gel microgestin fe minocycline mirtazapine modafinil mometasone mononessa montelukast morphine sulfate ext-release MOVIPREP MOXEZA multivitamins/fluoride mupirocin MUSE MYRBETRIQ N nabumetone nadolol NAMENDA, NAMENDA XR naproxen, naproxen sodium NASCOBAL NASONEX NATAZIA neomycin/polymyxin/ hydrocortisone ear drops NEVANAC NEXIUM NIASPAN nifedipine ext-release nitrofurantoin macrocrystal NITROLINGUAL PUMPSPRAY NORDITROPIN [INJ] nortriptyline NOVOFINE NUCYNTA, NUCYNTA ER NUEDEXTA NUVARING nystatin nystatin/triamcinolone O ofloxacin eye solution olanzapine omeprazole delayed-release ondansetron ondansetron orally disintegrating tablets ONETOUCH KITS/METERS; BASIC, ULTRA 2, ULTRAMINI, ULTRASMART, VERIO IQ (continued) PRMTPDLA-14

31 ONETOUCH TEST STRIPS; FASTTAKE, ONETOUCH, SURESTEP, ULTRA, VERIO ONGLYZA OPANA ER ORACEA ORENCIA [INJ] orsythia ORTHOVISC [INJ] oxcarbazepine oxybutynin oxybutynin ext-release oxycodone oxycodone/acetaminophen OXYCONTIN OXYTROL P pantoprazole delayed-release paroxetine PATADAY PATANOL PEGASYS, PEGASYS PROCLICK [INJ] penicillin v potassium PENTASA PERFOROMIST pioglitazone polymyxin/trimethoprim potassium chloride ext-release POTIGA PRADAXA pramipexole PRAMOSONE, PRAMOSONE E PRANDIMET pravastatin prednisolone prednisolone acetate prednisolone sodium phosphate prednisone PREMARIN TABS PREMPHASE PREMPRO PRISTIQ PROAIR HFA PROCRIT [INJ] PRODIGY INSULIN SYR, PEN NEEDLES progesterone micronized PROLENSA promethazine promethazine/ dextromethorphan propranolol propranolol ext-release PROTOPIC PULMICORT FLEXHALER PYLERA Q QNASL quetiapine QUILLIVANT XR quinapril QVAR R ramipril RANEXA ranitidine RAPAFLO REBIF, REBIF REBIDOSE [INJ] reclipsen RECTIV RELISTOR [INJ] RELPAX RENVELA RESTASIS RIOMET risperidone rizatriptan rizatriptan orally disintegrating tablets ropinirole S SAFYRAL SANCUSO SAVELLA SEREVENT DISKUS SEROQUEL XR sertraline SIMCOR simvastatin SOLARAZE SOLODYN 55 MG, 65 MG, 80 MG, 105 MG, 115 MG SOMATULINE DEPOT [INJ] sotalol SPIRIVA spironolactone sprintec STRATTERA SUBOXONE SL FILM SUCLEAR sucralfate sulfamethoxazole/ trimethoprim sumatriptan SUMAVEL DOSEPRO [INJ] SUPREP SYMBICORT SYMLINPEN [INJ] T TACLONEX TAMIFLU tamoxifen tamsulosin ext-release TARKA TAZORAC TECFIDERA TEKAMLO TEKTURNA, TEKTURNA HCT temazepam terazosin terconazole testosterone cypionate [INJ] timolol maleate eye solution tizanidine TOBRADEX OINTMENT TOBRADEX ST tobramycin eye solution tobramycin/ dexamethasone susp topiramate TOVIAZ TRACLEER tramadol tramadol/acetaminophen TRAVATAN Z travoprost trazodone hcl tretinoin TREXIMET triamcinolone acetonide nasal spray triamcinolone acetonide topical triamterene/ hydrochlorothiazide TRIBENZOR TRILIPIX trinessa tri-previfem tri-sprintec TUDORZA U UCERIS ULORIC V VAGIFEM valacyclovir valsartan/ hydrochlorothiazide VASCEPA VELTIN venlafaxine venlafaxine ext-release VENTOLIN HFA verapamil ext-release veripred VESICARE VGO VIAGRA VICTRELIS VIGAMOX VIIBRYD VIMOVO VIMPAT VIRAMUNE XR VIVELLE-DOT VOLTAREN GEL VYTORIN VYVANSE W warfarin WELCHOL X XARELTO XIFAXAN Z ZEMPLAR ZENPEP (EXCEPT 5,000 U) ZETIA ZIANA zolmitriptan zolmitriptan orally disintegrating tablets zolpidem zolpidem ext-release ZOMIG NASAL ZYCLARA ZYLET ZYMAXID ZYTIGA Excluded Medications With Covered Preferred Alternatives The following is a list of excluded brand-name medications with covered preferred alternatives that are on the formulary. Column 1 lists excluded medications. Column 2 lists covered preferred alternatives that can be prescribed. Excluded Medications ACCU-CHEK METERS/STRIPS ADVAIR DISKUS/HFA ALVESCO APIDRA AUVI-Q AVINZA BECONASE AQ BETASERON BRAVELLE BREEZE, CONTOUR METERS/STRIPS BREO ELLIPTA CIMZIA EDARBI/EDARBYCLOR EXALGO FLOVENT DISKUS/HFA FOLLISTIM AQ FORTESTA FREESTYLE, PRECISION METERS/STRIPS JENTADUETO KADIAN KAZANO LEVITRA MAXAIR AUTOHALER MICARDIS/MICARDIS HCT NESINA NOVOLIN NOVOLOG NUTROPIN/NUTROPIN AQ OMNARIS OMNITROPE PEGINTRON PROVENTIL HFA RHINOCORT AQUA SAIZEN SIMPONI STAXYN STELARA TESTIM TEVETEN/TEVETEN HCT TEV-TROPIN TRADJENTA TRUETEST, TRUETRACK METERS/STRIPS VERAMYST VICTOZA XELJANZ XOPENEX HFA ZETONNA ZIOPTAN Covered Preferred Alternative(s) OneTouch meters/strips Dulera, Symbicort Asmanex, Pulmicort Flexhaler, QVAR Humalog Epipen, Epipen Jr morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, Opana ER, Oxycontin flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl Avonex, Extavia, Rebif Gonal-f OneTouch meters/strips Dulera, Symbicort Enbrel, Humira candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, Benicar/HCT morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, Opana ER, Oxycontin Asmanex, Pulmicort Flexhaler, QVAR Gonal-f Androgel, Axiron OneTouch meters/strips Janumet, Janumet XR, Kombiglyze XR morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, Opana ER, Oxycontin Janumet, Janumet XR, Kombiglyze XR Cialis, Viagra Proair HFA, Ventolin HFA candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, Benicar/HCT Januvia, Onglyza Humulin Humalog Genotropin, Humatrope, Norditropin flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl Genotropin, Humatrope, Norditropin Pegasys Proair HFA, Ventolin HFA flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl Genotropin, Humatrope, Norditropin Enbrel, Humira Cialis, Viagra Enbrel, Humira Androgel, Axiron candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, Benicar/HCT Genotropin, Humatrope, Norditropin Januvia, Onglyza OneTouch meters/strips flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl Bydureon, Byetta Enbrel, Humira Proair HFA, Ventolin HFA flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl latanoprost, travoprost, Lumigan, Travatan Z KEY The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only. For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, THIS LIST IS SUBJECT TO CHANGE. You can get more information and updates to this document at our website at Express Scripts Holding Company All Rights Reserved PRMTPDLA-14

32 2014 Preferred Drug List Exclusions As of Jan. 1, 2014, the excluded medications shown below are not covered on the Express Scripts drug list.* In most cases, if you fill a prescription for one of these drugs after Jan. 1, you will pay the full retail price. Take action to avoid paying full price. If you are currently using one of the excluded medications, please ask your doctor to consider writing a new prescription for one of the following safe and effective covered alternatives. Drug Class Excluded Medications Covered Alternatives ANTINEOPLASTIC/ IMMUNOSUPPRESSANT Biologics Injectable Tumor Necrosis Factor Antagonists and Other Drugs for Inflammatory Conditions Cimzia, Simponi, Stelara, Xeljanz Enbrel, Humira AUTONOMIC & CENTRAL NERVOUS SYSTEM Interferon Beta Medications for Multiple Sclerosis Long-Acting Opioid Oral Analgesics Betaseron Avinza, Exalgo, Kadian Avonex, Extavia, Rebif morphine sulfate ER, oxymorphone ER, Nucynta ER, Opana ER, Oxycontin CARDIOVASCULAR Angiotensin II Receptor Antagonists + Diuretic Combinations DIABETES Blood Glucose Meters & Strips Dipeptidyl Peptidase-IV Inhibitors & Combos Edarbi/Edarbyclor, Micardis/Micardis HCT, Teveten/Teveten HCT Abbott (Freestyle, Precision), Bayer (Breeze, Contour), Nipro (TRUEtrack, TRUEtest), Roche (Accu-Chek) Jentadueto, Kazano, Nesina, Tradjenta candesartan/hydrochlorothiazide (HCTZ), irbesartan/hctz, losartan/hctz, valsartan/hctz, Benicar/HCT LifeScan (OneTouch) Janumet, Janumet XR, Januvia, Kombiglyze, Onglyza Incretin Mimetics (Glucagon-Like Peptide-1 Agonists) Victoza Bydureon, Byetta Insulins EAR/NOSE Nasal Steroids ENDOCRINE (OTHER) Androgen Drugs (Topical Testosterone Products) Novolin Apidra, NovoLog Beconase AQ, Omnaris, Rhinocort Aqua, Veramyst, Zetonna Fortesta, Testim Humulin Humalog flunisolide, fluticasone propionate, triamcinolone acetonide, Nasonex, Qnasl Androgel, Axiron Growth Hormones Nutropin/Nutropin AQ, Omnitrope, Saizen, Tev-Tropin Genotropin, Humatrope, Norditropin *These changes apply to most Express Scripts national drug lists; does not apply to Medicare plans. Continue on back

33 Continued Drug Class Excluded Medications Covered Alternatives IMMUNOLOGICAL Interferons PegIntron Pegasys OBSTETRICAL & GYNECOLOGICAL Ovulatory Stimulants (Follitropins) Bravelle, Follistim AQ Gonal-f OPHTHALMIC Antiglaucoma Drugs (Ophthalmic Prostaglandins) Zioptan latanoprost, travoprost, Lumigan, Travatan Z RESPIRATORY Epinephrine Auto-Injector Systems Auvi-Q EpiPen, EpiPen Jr Pulmonary Anti-Inflammatory Inhalers Alvesco, Flovent Diskus/HFA Asmanex, Pulmicort Flexhaler, QVAR Pulmonary Anti-Inflammatory/ Beta Agonist Combination Inhalers Advair Diskus/HFA, Breo Ellipta Dulera, Symbicort Beta-2 Adrenergics (Short-Acting Inhalers) Maxair Autohaler, Proventil HFA, Xopenex HFA Proair HFA, Ventolin HFA UROLOGICAL Erectile Dysfunction Oral Agents Levitra, Staxyn Cialis, Viagra Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to Express-Scripts.com/covered to access cost-savings tools that provide pricing and coverage information for specific medications. Other prescription benefit considerations may apply. Excluded Medications/Products at a Glance Abbott Meters & Strips (Freestyle, Precision) Advair Diskus/HFA Alvesco Apidra Auvi-Q Avinza Bayer Meters & Strips (Breeze, Contour) Beconase AQ Betaseron Bravelle Breo Ellipta Cimzia Edarbi/Edarbyclor Exalgo Flovent Diskus/HFA Follistim AQ Fortesta Jentadueto Kadian Kazano Levitra Maxair Autohaler Micardis/Micardis HCT Nesina Nipro Meters & Strips (TRUEtrack, TRUEtest) Novolin NovoLog Nutropin/Nutropin AQ Omnaris Omnitrope PegIntron Proventil HFA Rhinocort Aqua Roche Meters & Strips (Accu-Chek) Saizen Simponi Staxyn Stelara Testim Teveten/Teveten HCT Tev-Tropin Tradjenta Veramyst Victoza Xeljanz Xopenex HFA Zetonna Zioptan If you have any questions, please call the number on your member ID card. Express Scripts manages your prescription benefit for your employer, plan sponsor or health plan Express Scripts Holding Company. All Rights Reserved. Express Scripts and E Logo are trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the property of their respective owners. EME19640 DL44109Q

34