Customer Service

Southern Utah University2019 Member Guide

emihealth.com

Toll Free: Local:

800.662.5851 801.262.7475

Administered by Educators Mutual Insurance Association

EMI Health Customer Service 801-262-7475 or 1-800-662-5851

Self Funded Employee Medical Benefit Plan

Southern Utah University #144

July 01, 2019 - June 30, 2020 Participating Non-Participating

Traditional Provider Option Provider Option

GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit

Out-of-Pocket Maximum (Per Person/Family Per Year). Please note * $3,500 / $7,000 $7,000 / $14,000

Medical Deductible (Per Person/Family Per Year - Separate from and not satisfied

by the Prescription Drug Deductible). Please note ♦$1,000 / $1,500 $1,500 / $3,000

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

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

PRESCRIPTION DRUG BENEFITS - Administered by Magellan Rx (If brand is

purchased when generic is available, member pays the copay plus the

difference between the generic and the brand price)

Prescription Drug Deductible (Per Person/Family Per Year - Separate from and not

satisfied by the Medical Deductible). Please note ●

Participating Pharmacy (30 day supply)

Non-Participating Pharmacy

Mail Order (90 day supply)

Specialty Drug (90 day supply)

PREVENTIVE SERVICES

Routine Physical Exam (1 visit per Year) Covered 100% ♦40%

Routine Gynecological Exam (1 visit per Year) Covered 100% ♦40%

Family History Exam (1 visit per Year) Covered 100% ♦40%

Routine Pap Smear & Mammogram (1 per Year) Covered 100% ♦40%

Routine Well-Baby Exams Covered 100% ♦40%

Covered Immunizations Covered 100% ♦40%

Routine Vision Exam (1 visit per Year) Covered 100% ♦40%

Routine Hearing Exam (1 visit per Year) Covered 100% ♦40%

PHYSICIAN & PROFESSIONAL SERVICES

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

Physician Office Visits (secondary care) $45 ♦40%

Physician Office Visits (after hours) $45 ♦40%

Physician Visits (Inpatient) ♦20% ♦40%

Physician Visits (Outpatient) ♦20% ♦40%

Major Diagnostic Test, CT Scan, MRI, NMR (office) ♦20% ♦40%

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

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

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

Injections (office) 20% ♦40%

Surgery (office) 20% ♦40%

Surgery (Inpatient) ♦20% ♦40%

Surgery (Outpatient) ♦20% ♦40%

Anesthesiology (office) 20% ♦40%

Anesthesiology (Inpatient) ♦20% ♦40%

Anesthesiology (Outpatient) ♦20% ♦40%

Routine Prenatal & Delivery (Dependent maternity included) ♦20% ♦40%

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

Supplies and Equipment)♦20% ♦40%

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

pulmonary - 30 visits per Year)$45 ♦40%

Chiropractic Therapy (10 visits per Year) $45 ♦40%

Allergy Testing 20% ♦40%

YOU PAY

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

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

Care Plus

●Preferred - 30% ($250 Max)

Contract Year

26

YOU PAY

$50 / $150

●Generic - $10

YOU PAY

●Non-Preferred - 50% ($350 Max)

Not Covered

●Generic - $20

●Preferred - 30% ($250 Max)

●Non-Preferred - 50% ($350 Max)

● Tier 1 - 15% ($200 Max)

● Tier 2 - 25% ($275 Max)

● Tier 3 - 40% ($400 Max)

● Tier 4 - Excluded Prescriptions

YOU PAY

Southern Utah University #144

July 01, 2019 - June 30, 2020 Participating Non-Participating

Traditional Provider Option Provider Option

Care Plus

Allergy Treatment/Serum 20% ♦40%

HOSPITAL/FACILITY BENEFITS

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

Medical/Surgical/Maternity/Intensive Care (semi-private room) ♦20% ♦40%

Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) ♦20% ♦40%

Skilled Nursing Facility (60 days per Year) (Admission must be within 5 days of

discharge from Hospital Confinement)♦20% ♦40%

Medical/Surgical Care (Outpatient) ♦20% ♦40%

Emergency Room (ER) $300 $300

Major Diagnostic Test, CT Scan, MRI, NMR (Outpatient) ♦20% ♦40%

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

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

Newborn 20% 40%

InstaCare/Urgent Care Clinic $45 ♦40%

Eligible Preventive Services Covered 100% Not Covered

REHABILITATION THERAPY BENEFIT

Inpatient – physical, speech, occupational, cardiac, or pulmonary (30 days per

person per Year)♦20% ♦40%

ACCIDENT AND LIFE THREATENING CONDITION

Supplemental Accident/Life-Threatening Illness Benefit

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

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

Orthodontic Injury Treatment ♦50%

Dental Injury Treatment ♦20%

TRANSPLANT BENEFIT

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

MEDICAL SUPPLIES & EQUIPMENT

Diabetic Testing Supplies (90 day supply) 30% ♦40%

Medical Supplies ♦20% ♦40%

Medical Supplies (office) Covered 100% ♦40%

Durable Medical Equipment/Prosthetics/Orthotic Devices ♦20% ♦40%

Orthotic Supplies (foot inserts & arch supports) ♦20% ♦40%

Growth Hormone ♦20% ♦40%

MENTAL HEALTH & DRUG/ALCOHOL TREATMENT

Inpatient Services (non-residential) ♦20% ♦40%

Residential Treatment Not Covered Not Covered

Outpatient Services ♦20% ♦40%

Physician Office Visits

Psychologist / LCSW / APRN / Psychiatrist$45 ♦40%

ADDITIONAL BENEFITS YOU PAY

Adoption Indemnity Benefit

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

Orthognathic/Mandibular Osteotomy ♦50% Not Covered

Total Parenteral Nutrition (TPN) ♦50% Not Covered

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

Reduction Mammoplasty ♦50% Not Covered

Autism Applied Behavior Analysis (Ages 2 thru 9, up to 600 hours per Year) ♦20% ♦40%

Services designated ● are subject to first dollar Prescription Drug Deductible.

Services designated ♦ are subject to first dollar Medical Deductible

PROVIDER NETWORK

Utah

Outside of Utah

YOU PAY

YOU PAY

YOU PAY

Covered 100% for first $1000 per Year then regular benefits apply

Covered as a Participating Benefit to

the Maximum Allowable Charge

YOU PAY

YOU PAY

YOU PAY

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

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

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

Customer Service Department.

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

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

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

EMI Health Care Plus

Cigna PPO

Administered by Educators Mutual Insurance Association

EMI Health Customer Service 801-262-7475 or 1-800-662-5851

Self Funded Employee Medical Benefit Plan

Southern Utah University #144

July 01, 2019 - June 30, 2020 Participating Non-Participating

QHDHP Provider Option Provider Option

GENERAL INFORMATION

Benefit Accumulator

Dependent Age Limit

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

Medical Deductible (Per Single/Family Per Year). Please note ♦ $1,750 / $3,500 $3,500 / $7,000

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

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

PRESCRIPTION DRUG BENEFITS - Administered by Magellan Rx (If brand is

purchased when generic is available, member pays the copay plus the

difference between the generic and the brand price)

Participating Pharmacy (30 day supply)

Non-Participating Pharmacy

Mail Order (90 day supply)

Specialty Drug (90 day supply)

PREVENTIVE SERVICES

Routine Physical Exam (1 visit per Year) Covered 100% ♦40%

Routine Gynecological Exam (1 visit per Year) Covered 100% ♦40%

Family History Exam (1 visit per Year) Covered 100% ♦40%

Routine Pap Smear & Mammogram (1 per Year) Covered 100% ♦40%

Routine Well-Baby Exams Covered 100% ♦40%

Covered Immunizations Covered 100% ♦40%

Routine Vision Exam (1 visit per Year) Covered 100% ♦40%

Routine Hearing Exam (1 visit per Year) Covered 100% ♦40%

PHYSICIAN & PROFESSIONAL SERVICES

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

Physician Office Visits (secondary care) ♦$45 ♦40%

Physician Office Visits (after hours) ♦$45 ♦40%

Physician Visits (Inpatient) ♦20% ♦40%

Physician Visits (Outpatient) ♦20% ♦40%

Major Diagnostic Test, CT Scan, MRI, NMR (office) ♦20% ♦40%

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

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

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

Injections (office) ♦20% ♦40%

Surgery (office) ♦20% ♦40%

Surgery (Inpatient) ♦20% ♦40%

Surgery (Outpatient) ♦20% ♦40%

Anesthesiology (office) ♦20% ♦40%

Anesthesiology (Inpatient) ♦20% ♦40%

Anesthesiology (Outpatient) ♦20% ♦40%

Routine Prenatal & Delivery (Dependent maternity included) ♦20% ♦40%

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

Supplies and Equipment)♦20% ♦40%

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

pulmonary - 30 visits per Year)♦$45 ♦40%

Chiropractic Therapy (10 visits per Year) ♦$45 ♦40%

Allergy Testing ♦20% ♦40%

YOU PAY

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

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

Care Plus

♦Preferred - 30% ($250 Max)

Contract Year

26

YOU PAY

♦Generic - $10

YOU PAY

♦Non-Preferred - 50% ($350 Max)

Not Covered

♦Generic - $20

♦Preferred - 30% ($250 Max)

♦Non-Preferred - 50% ($350 Max)

♦ Tier 1 - 15% ($200 Max)

♦ Tier 2 - 25% ($275 Max)

♦ Tier 3 - 40% ($400 Max)

♦ Tier 4 - Excluded Prescriptions

YOU PAY

Southern Utah University #144

July 01, 2019 - June 30, 2020 Participating Non-Participating

QHDHP Provider Option Provider Option

Care Plus

Allergy Treatment/Serum ♦20% ♦40%

HOSPITAL/FACILITY BENEFITS

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

Medical/Surgical/Maternity/Intensive Care (semi-private room) ♦20% ♦40%

Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) ♦20% ♦40%

Skilled Nursing Facility (60 days per Year) (Admission must be within 5 days of

discharge from Hospital Confinement)♦20% ♦40%

Medical/Surgical Care (Outpatient) ♦20% ♦40%

Emergency Room (ER) ♦20% ♦20%

Major Diagnostic Test, CT Scan, MRI, NMR (Outpatient) ♦20% ♦40%

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

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

Newborn ♦20% ♦40%

InstaCare/Urgent Care Clinic ♦20% ♦40%

Eligible Preventive Services Covered 100% Not Covered

REHABILITATION THERAPY BENEFIT

Inpatient – physical, speech, occupational, cardiac, or pulmonary (30 days per

person per Year)♦20% ♦40%

ACCIDENT AND LIFE THREATENING CONDITION

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

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

Orthodontic Injury Treatment ♦20%

Dental Injury Treatment ♦20%

TRANSPLANT BENEFIT

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

MEDICAL SUPPLIES & EQUIPMENT

Diabetic Testing Supplies (90 day supply) ♦30% ♦40%

Medical Supplies ♦20% ♦40%

Medical Supplies (office) ♦20% ♦40%

Durable Medical Equipment/Prosthetics/Orthotic Devices ♦20% ♦40%

Orthotic Supplies (foot inserts & arch supports) ♦20% ♦40%

Growth Hormone ♦20% ♦40%

MENTAL HEALTH & DRUG/ALCOHOL TREATMENT

Inpatient Services (non-residential) ♦20% ♦40%

Residential Treatment Not Covered Not Covered

Outpatient Services ♦20% ♦40%

Physician Office Visits

Psychologist / LCSW / APRN / Psychiatrist♦$45 ♦40%

ADDITIONAL BENEFITS YOU PAY

Adoption Indemnity Benefit

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

Orthognathic/Mandibular Osteotomy ♦20% Not Covered

Total Parenteral Nutrition (TPN) ♦20% Not Covered

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

Reduction Mammoplasty ♦50% Not Covered

Autism Applied Behavior Analysis (Ages 2 thru 9, up to 600 hours per Year) ♦20% ♦40%

Services designated ♦ are subject to first dollar Medical Deductible

PROVIDER NETWORK

Utah

Outside of Utah

YOU PAY

YOU PAY

YOU PAY

Covered as a Participating Benefit to

the Maximum Allowable Charge

YOU PAY

YOU PAY

YOU PAY

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

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

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

Customer Service Department.

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

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

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

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

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

family.

EMI Health Care Plus

Cigna PPO

Corporate (801)262-7475Customer Service (800)662-5851

EMIHealth.com

DENTAL COVERAGE

OUTLINE OF COVERAGE

Southern Utah University (Plan #144) Premier PPOEducators Mutual Insurance Association, a Utah Company7/1/2019ContractContributory / Self Funded

Underwritten & Administered by:

Network / Reimbursement Schedule

Covered in Type 3 - Major

Covered in Type 3 - Major**Covered in Type 3 - Major**

Periapical X-Rays

Covered in Type 2 - Basic1 every 3 years

Space Maintainers

Anesthesia - (For children age 7 and under, once per year)

6 per yearUp to 4, twice per year

Up to age 16

Panoramic X-Ray

Provisions / Limitations / Exclusions

* All Services are subject to EMI Health Table of Allowances (TOA). When using a Non-participating Provider, the insured is responsible for all fees in excess of the Table of Allowances (TOA).

Implants / Implant Abutments

Any Age 2 per year

Anesthesia- (Age 8 and over for the extraction of impacted teeth only)

Sealants

Impacted Teeth

Fluoride

Fillings on the same surfaceCrowns, Pontics, Abutments, Onlays and Dentures

Up to age 26

1 every 18 months1 every 5 years per tooth

Bitewing X-Rays

** Anesthesia is not subject to waiting periods.

NoneType 4 - Orthodontics

Type 2 - Basic

Orthodontic Lifetime Maximum

Per PersonFamily Max

Deductible Applies To

Annual Maximum Per Person$1,500.00

$0.00$0.00$0.00

N / A

$2,000.00

Premier Premier

N / A$0.00

Effective Date:

Orthodontic Discount (All Members) Up to 25% Discount

50%

Type 1 - PreventiveOral Exams, Cleanings, X-rays, Fluoride

Type 2 - BasicFillings, Oral Surgery

Type 3 - Major

Adults

Crowns, Bridges, Prosthodontics

Type 4 - Orthodontics

50%

Type 3 - Major

50% up to TOA*

Type 2 - BasicType 2 - Basic

No Discount

Dependent children ages 7 through 1850%

80% up to TOA*

50%

Type 2 - BasicType 2 - Basic

50%

PeriodonticsEndodontics

Type 3 - MajorType 1 - Preventive

None

Waiting periods

Space MaintainersSealants

None

Type 3 - Major

BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL DENTAL EXPENSES

Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and

your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!

Group:Plan:

Plan Type:Benefit Year:

Exams (including Periodontal), Cleanings and Fluoride

Deductible

Type 1 - Preventive

Out-of-NetworkIn-Network

100%

80%

100% up to TOA*

852 EAST ARROWHEAD LANEMURRAY, UT 84107

CORPORATE (801)262-7475TOLL FREE (800)662-5851

EMIHealth.com

Group: Southern Utah University (Plan #144)Plan: Vision 130BUnderwritten by / Administered by: Opticare of Utah / Educators Health Plans Life, Accident & HealthPlan Type: Voluntary

7/1/2019Contract

In-Network Out-of-Network

Single Vision $10 Co-pay

Bifocal (FT 28) $10 Co-pay

Trifocal (FT 7*28) $10 Co-pay

*Progressive (Standard no-line) $50 Co-pay

*Premium Progressive Options No Discount

Glass Lenses 15% Discount

Polycarbonate 25% Discount

High Index 25% Discount

Scratch Resistant Coating $10 Co-pay

Ultra Violet protection $10 Co-pay

Other Options

A/R edge polish, tints, mirrors, etc.

Allowance Based on Retail Pricing $130 Allowance ▲ $90 Allowance**Additional Pairs of Glasses Throughout the Year

Contact benefits is in lieuof lens and frame benefit.Additional contact purchases:***Conventional Retail***Disposables Retail

Lenses, Frames, Contacts Every 12 Months Every 12 Months

****LASIK $250 Off Per Eye Not Covered

EmployeeTwo PartyFamily

Discounts - Any item listed as a discount in the benefit outline above is a merchandise discount only and not an insured benefit. Providers may offer additional discounts.

* Co-pays for Progressive lenses may vary. This is a summary of plan benefits. The actual Policy will detail all plan limitations and exclusions.

**50% discount at Standard Optical locations Only. All other Network discounts vary from 20% - 35%

***Must purchase full year supply to receive discounts on select brands. See provider for details.

****LASIK (Refractive surgery) Standard Optical Locations ONLY.

LASIK services are not an insured benefit; this is a discount only. All pre & post operative care is provided by Standard Optical Only and is based on

Standard Optical retail fees.

▲ Out of Network – Allowances are reimbursed at 75% when discounts are applied to merchandise. Promotional items or Online purchases not covered.

Effective Date:Benefit Year:

Eye Exam No Eye Exam Benefit

Lenses

▲ $85 Allowance for lense, options, and coatings

Lens Options

Coatings

Up to 25% Discount

Frames

Up to 50% Off Retail

Contacts

$130 Allowance ▲ $90 Allowance

Frequency

Refractive Surgery

Monthly Rates$4.10$7.90

$12.60

BASIC ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE OVERVIEW

Prepared for the employees of Educators Mutual Insurance Association

Basic AD&D Insurance Coverage – paid by your employer

Eligibility Active Employees of a participating Employer in the Educators Mutual Insurance Association

Employee Benefit Amount and Maximum $5,000

Other Accidental Death & Dismemberment (AD&D) Coverage Features A Valuable Combination of Benefits To help survivors of severe accidents adjust to new living circumstances, we will pay benefits according to the chart below.

Only one benefit (the largest) will be paid for losses from the same accident.

Additional Benefits of Personal Accident Insurance For Wearing a Seatbelt & Protection by an Airbag - Additional 10% benefit but not more than $500 if the covered person dies in an automobile accident while wearing a seatbelt. We will increase the benefit by an additional 5% but not more than $250 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag).

For Comas - 1% of full benefit amount, for up to 11 months, if you are in a coma for 30 days or more as a result of a covered accident. If the covered person is still in a coma after 11 months, or dies, the full benefit amount will be paid.

For Exposure & Disappearance - Benefits are payable if you suffer a covered loss due to unavoidable exposure to the elements as a result of a covered accident. If you body is not found within one year of the disappearance, wrecking or sinking of the conveyance in which you or an insured family member were riding, on a trip otherwise covered, it will be presumed that you sustained loss of life as a result of a covered accident.

What is Not Covered Self-inflicted injuries or suicide while sane or insane • commission or attempt to commit a felony or an assault • any act of war, declared or undeclared • any active participation in a riot, insurrection or terrorist act • bungee jumping • parachuting • skydiving • parasailing • hang-gliding • sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food• voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed • operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it • a Covered Accident that occurs while the covered person is engaged in the activities of active duty service in the military, navy or air force of any country or international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days) • traveling in an aircraft that is owned,

If, within 365 days of a covered accident, bodily injuries result in: We will pay this % of the benefit amount:

Loss of life 100%

Total paralysis of upper and lower limbs, or Loss of any combination of two: hands, feet or eyesight, or Loss of speech and hearing in both ears

100%

Total paralysis of both lower or upper limbs 75%

Total paralysis of upper and lower limbs on one side of the body, or Loss of hand, foot or sight in one eye, or Loss of speech or loss of hearing in both ears, or Severance and Reattachment of one hand or foot

50%

Total paralysis of one upper or lower limb, or Loss of all four fingers of the same hand, or Loss of thumb and index finger of the same hand

25%

Loss of all toes of the same foot 20%

leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates • air travel, except as a passenger on a regularly scheduled commercial airline or in an aircraft being used by the Air Mobility Command or its foreign equivalent • flight in, boarding or alighting from an Aircraft or any craft designed to fly above the Earth’s surface being flown by the covered person or in which the covered person is a member of the crew.

When Your Coverage Begins and Ends Coverage becomes effective on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Coverage will continue while you remain eligible, the group policy is in force, and required premiums are paid.

Conversion - If, before you reach age 70, this group coverage is reduced or ends for any reason except non-payment of premium or age, you can convert to an individual policy. No medical certification is needed. To continue coverage, you must apply for the conversion policy and pay the first premium in effect for your age and occupation within 31 days after your group coverage ends. Converted policies are subject to certain benefits and limits as outlined in your certificate, should you become insured under the plan.

This information is a brief description of the important features of the plan. It is not a contract. Terms and conditions of coverage are set forth in Group Policy No. OK969334. Please refer to your Certificate of Insurance or Summary Plan Description for more detailed information. Coverage is underwritten by Life Insurance Company of North America, a Cigna company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © Cigna 2015

Your ID Card (f ron t )It is im por t an t t hat you p resen t you r ID card each t im e you receive services. Your EMI Health ID card con tains a lot of usefu l in form at ion for you and your p rovider.

Card Fron t

D

GH

I

J

K

F

E

C

B

A

A EMI Health is your insurance carrier.

B The em ployee's nam e is listed on the ID card . Covered dependents are not listed .

C Th is is the nam e of your m ed ical p lan and also ind icates your part icipat ing p rovider netw ork. To verify a p rovider's status, visit em ihealth .com or call 800-662-5851.

D These are your basic copay, coinsurance, and deduct ib le am ounts w hen you visit a part icipat ing p rovider. For m ore detailed benef it s in form at ion , see your Sum m ary of Benef it s and m em ber handbook.

E Th is is your m ed ical part icipat ing p rovider netw ork w hen t raveling outside of Utah . To verify a p rovider's status, visit em ihealth .com or call 800-662-5851.

I If you have dental coverage w ith EMI Health , the nam e of your dental p lan w ill appear here. Th is also ind icates your dental part icipat ing p rovider netw ork. To verify a p rovider's status, visit em ihealth .com or call 800-662-5851. If t h is sect ion is not on your card , you do not have dental coverage th rough EMI Health .

F Your un ique m em ber num ber is requ ired in order to verify coverage, determ ine benef it s, and pay claim s for you and your dependents.

G Express Scrip ts is your Pharm acy Benef it s Manager.

H These are your basic pharm acy copays and coinsurance am ounts. K Th is is the phone num ber to call for a

Telem ed consu ltat ion w ith a WellVia physician . EMI Telem ed can elim inate the need for off ice visit s for m any com m on cond it ions.

If t h is sect ion is not on your card , you do not have TeleMed services th rough EMI Health .

J If you have vision coverage w ith EMI Health , the nam e of your vision p lan w ill appear here. Th is also ind icates your vision part icipat ing p rovider netw ork. To verify a p rovider's status, visit em ihealth .com or call 800-662-5851.

If t h is sect ion is not on your card , you do not have vision coverage th rough EMI Health .

Your ID Card (back)

Card Back

A

B

C

D

E

B Th is is the telephone num ber to call for custom er service inqu iries.

C These are your part icipat ing p rovider m ed ical netw orks for Utah and nat ionally. To verify a p rovider's status, visit em ihealth .com or call 800-662-5851.

D Th is is the telephone num ber to call for p reauthorizat ions.

A Th is is the claim s subm ission address for Utah m ed ical claim s and all den tal claim s. In m ost cases, your p rovider w ill subm it claim s d irect ly to EMI Health .

E These are your part icipat ing p rovider dental netw orks outside of Utah . To verify a p rovider's status, visit em ihealth .com or call 800-662-5851.

If t h is sect ion is not on your card , you do not have dental coverage th rough EMI Health .

Read ing Your EOB

Read ing Your EOB

Prevent ive CarePreven t ive care det ect s pot en t ial p rob lem s early w h en t h ey are easier t o t reat . The Affordab le Care Act (ACA) p rovides for p revent ive services rated A or B to be covered 100 percent w hen received by part icipat ing p roviders.

Prevent ive services are those p rovided w hen no sym ptom s or d iagnosed m ed ical cond it ions exist . For services to be covered as p revent ive, your doctor m ust b ill claim s w ith p revent ive codes. If a p revent ive service iden t if ies a cond it ion that needs further test ing or t reatm ent , regu lar copaym ents, coinsurance, or deduct ib les m ay app ly.

Here are som e som e p reven t ive services covered w it h n o pat ien t cost :

- Rout ine physical exam- Rout ine vision exam- Rout ine hearing exam

- Rout ine gynecolog ical exam- Rout ine Pap sm ear- Screen ing m am m ogram

Im m unizat ions recom m ended by the Advisory Com m it tee on Im m unizat ions Pract ices of the Center for Disease Cont rols and Prevent ion (CDC) are covered 100 percent if received f rom a part icipat ing p rovider. As of Novem ber 2017, those recom m endat ions are as follow s:

Find the fu ll list of p revent ive services at h t tp ://b it .ly/USPSTF_AB. The list is sub ject to change based on federal gu idelines. Th is in form at ion does not app ly to g randfathered p lans. Please see your sum m ary of benef it s and m em ber handbook on the details of your specif ic p lan .

VACCINE Birth 1 Mo 2 Mo 4 Mo 6 Mo 12 Mo 15 Mo 18 Mo 19-23 Mo 2-3 Yrs 4-6 Yrs 7-10 Yrs 11-12 Yrs 13-18 Yrs

Hepat it is B HepB HepB HepB HepB Catch Up

Rotavirus RV RV RV

Diphtheria, Tetanus, Pertussis DTaP DTaP DTaP DTaP DTaPDTaP

Catch UpDTaP

DTaP Catch Up

Haem oph ilus In fluenzae Type b Hib Hib Hib Hib

Inact ivated Poliovirus IPV IPV IPV IPV Poliovirus Catch Up

Measles, Mum ps, Rubella MMR MMR MMR Catch Up

Varicella Varicella Varicella Varicella Catch Up

Pneum ococcal PCV PCV PCV PCV

In fluenza In fluenza (Yearly)

Hepat it is A HepA (2 Doses) HepA Catch Up

Meningococcal MenACW Y MenACW Y

Hum an Pap illom avirus HPVHPV

Catch Up

Children

VACCINE 19-26 Yrs27-49

Yrs50-59 Yrs 60-64 Yrs ? 65 Yrs

Diph theria, Tetanus, Pertussis (Td /Tdap One dose of Tdap; then boost w ith Td every 10 years

In fluenza One dose annually

Pneum ococcal 1 or 2 doses 1 dose

Zoster (Sh ing les)*Sh ing rix® vaccine: 2-dose im m unizat ion after 50

Zostavax® vaccine: 1-dose after age 60

IF NOT RECEIVED AS A CHILD

Measles Mum ps, Rubella MMR

Hum an Pap illom avirus HPV

Varicella Varicella

Adults

*Only one of the sh ing les vaccines are necessary. EMI Health covers both old and new vaccines. If you have already had the sh ing les vaccine, you do not need the new vaccine and a second, unnecessary vaccine is not covered by EMI Health .

Diabetes Managem entYour m ed ical p lan covers d iabet ic supp lies un der you r m ajor m ed ical ben ef it inst ead of t h e p rescrip t ion d rug ben ef it .

Here are som e com m on coverages. Contact custom er service for the specif ics of your p lan .

MAJOR MEDICAL BENEFITS?

PRESCRIPTION DRUG (PHARMACY) BENEFITS?

Most EMI Health p lans cover the follow ing supp lies under the Med ical Supp lies & Equ ipm ent benef it . Refer to the Diabet ic Test ing Supp lies (90-day supp ly) line item of your benef it sum m ary for your m em ber cost -share.

- Blood sugar (g lucose) test st rips - Lancet devices and lancets

EMI Health has con t racted p roviders for d iabetes test ing supp lies. Test ing supp lies ob tained th rough any other p rovider (includ ing pharm acies) m ay not be covered ; or if covered , w ill be sub ject to your Non-Part icipat ing Provider benef it op t ion .

The part icipat ing supp liers are

- Edgepark / Card inal - 877-215-2568 - Byram Healthcare - 800-775-4372 - JQ Med ical Supp ly - 801-942-8582

The follow ing item s are covered under the Durab le m ed ical Equ ipm ent benef it . See your benef it sum m ary for your m em ber cost -share.

- Therapeut ic shoes or insert s - Insu lin pum p and insu lin pum p supp lies, sub ject to p reauthorizat ion criteria and p lan review - Cont inuous Glucose Mon itoring System s (CGMS) and sensors, sub ject to p reauthorizat ion criteria and p lan review

- Diabet ic t est in g supp lies are covered un der t h e pharm acy ben ef it . The on ly b rand in the 2019 form ulary is One Touch. All other b rands are excluded f rom coverage.

- Insu lin is covered un der t h e pharm acy ben ef it . You m ay receive up to a 30-day supp ly (m axim um of tw o vials) per retail copaym ent or up to a 90-day supp ly (m axim um of six vials) per m ail-order copaym ent . If necessary, add it ional vials m ay be purchased by paying an add it ional copaym ent .

- Prescrip t ion m ed icin es for d iabet es are covered un der t h e pharm acy ben ef it . Th is includes Glucagon, GLP1 agents (i.e., Byet ta, Bydureon, Trad jen ta) and oral agents for Type 2 d iabetes (i.e., Glucophage, Avand ia, Am aryl).

Blood sugar test ing m on itors, g lucose cont rol solu t ions, and w eigh t loss m ed icat ions are NOT covered under the m ed ical or pharm acy benef it .

*Please refer to the Prescrip t ion Drug sect ion of your benef it sum m ary for your m em ber cost -share.

My EMI Health Account SetupAll you r ben ef it answ ers. On e w ebsit e. Find everyth ing related to your benef it s f rom general p lan docum ents to detailed claim s in form at ion .

Get St ar t ed

1. Go to em ihealth .com .

2. Click Log in and select My EMI Health .

3. Select Reg ister and choose Mem ber as the type of account .

4 . Enter the data to iden t ify yourself and click Cont inue.

* You w ill need your Mem ber ID found on your EMI Health ID card . Also, for your security, your passw ord m ust be at least six characters and include a special character, e.g ., !, @, # , $, etc.

W hat You Can Do

View benef it descrip t ions

Check claim s status

Order ID cards

View EOBs

Access the Sm art Cost Calcu lator

Review elig ib ilit y/enrollm ent status

Manage prescrip t ion benef it s

My EMI HealthAs a m em ber of EMI Heal t h , you have access t o t h e follow in g on lin e t ools an d services.

SMART COSTCAL CU L ATOR

Manag e you r m ed ical, den t al, v ision , an d d isab il it y p lans:

- View benef it descrip t ions- Review elig ib ilit y/enrollm ent status- Check claim s status- View Exp lanat ion of Benef it s (EOBs)- Order ID cards

My EMI Heal t hMy EMI Health

Manag e you r p rescrip t ion ben ef it s:

- Ref ill p rescrip t ions- Check order status- Price m ed icat ions- Locate part icipat ing pharm acies

Express Scrip t s

Com pare an d Save:

- Com pare costs of d ifferen t facilit ies- See the p rices of seeing specif ic p roviders- Find the cost of a certain p rocedure

Transparen cy Tool

Care is just a ph on e call aw ay:

- $0 physician consu ltat ions- 24 /7/365 access to physician care- Conven ience of care f rom your ow n hom e

TeleMed

TM

Your Exp lanat ion of Benef it s (EOB) can on ly be found on line th rough your My EMI Health account . It is im portan t to note that paper cop ies of your EOB are not m ailed .

im por t an t

Find Part icipat ing ProvidersFin d in -n et w ork p roviders. Save Mon ey.

1. Select the network type: Med ical, Den t al or Vision and choose your p lan (found on your ID Card). Med ical Plan : Care PlusDen t al Plans: Prem ier, Advantage, Value, Sum m it , or Sum m it PlusVision Plans: Opt icare, VSP Choice, or VSP Choice Plus

2. Now, en ter your p rovider's details and click Search .

Ut ah Provider Search

That 's all t here is to it !

You w ill see a list of part icipat ing p roviders along w ith their con tact in form at ion , address, and the ab ilit y to m ap the locat ion of their off ices. You can also dow nload the resu lt s as a PDF to p rin t .

To search for m ed ical p roviders in Utah or dental and vision p roviders both in Utah and nat ionally,go to em ih eal t h .com and click on Provider Search along the upper part of the hom e page.

To search for m ed ical p roviders outside Utah , go to em ih eal t h .com and click on Provider Search along the upper part of the hom e page.

1. Select m ed ical as the netw ork type and choose Care Plus as your p lan .Select the state in w h ich you 'd like to search . W hen you select a state other than Utah , you w ill be asked to select a logo. Ch oose t h e Cig na log o.

2. Once on the Cigna w ebsite, choose the type of p rovider (Doctor, Hosp ital, Pharm acy, or Facilit y).

3. Use your curren t locat ion or input the city/state in w h ich you 'd like to search .

4 . Under Select a Plan , choose PPO, Ch oice Fun d PPO

5. Under Look in g For , choose a specialty or facilit y type.

6. Now, en ter your p rovider's details and click Search .

Nat ional Cig na PPO Med ical Provider Search

Please Not e:Not all p lans have part icipat ing provider benef it s outside of your state of residence. To conf irm your benef it s, or if you have any quest ions, p lease contact the EMI Health custom er service team toll f ree at 800.662.5851.

In add it ion to being another conven ien t w ay to search for p roviders, the EMI Health m ob ile app allow s you to do even m ore.

Dow n load Th e Mob ile App To Search On Th e Go.

View your p lan g ridsView your ID Card .

Update your p rof ile in form at ion like em ail address, passw ord , or security quest ions.

View your EOBs and search by person, service, date, and m ore.

Access curren t and past issues of the Hope Health new slet ter.

Mobile AppYour ben ef it s. Anyt im e. Anyw h ere.

Scan th is QR codew ith your phone

to dow nload.

Find in -netw ork p roviders and facilit ies.

Provider Search

Need to talk to a person? No prob lem . Call us f rom the app.

Cust om er Service

Access your ID Card f rom anyw here at any t im e.

ID Card

View your EOBs and search by person, service, date, and m ore.

EOBs

View and dow nload your p lan g rids so you alw ays know the benef it s you have.

Plan In form at ion

Dow nload the app and log in using your My EMI Health usernam e and passw ord .

If you haven 't reg istered your account , you can do so in the app or on line at em ihealth .com .

Log in /Reg ist er

- Access curren t and past issues of the Hope Health new slet ter.

- Update your p rof ile in form at ion like em ail address, passw ord , or security quest ions.

Ot h er Feat u res

TeleMed icineReach a doct or 24 /7/365. Som e 70% of doctor visit s can be hand led over the phone, and 40% of urgent care visit s can be m anaged using TeleMed icine. Save t im e and m oney w h ile st ill get t ing the t reatm ent you need th rough EMI Health TeleMed offered th rough WellVia.

1-877-872-0370

*In accordance w ith telem ed icine gu idelines, ear in fect ions are on ly d iagnosed for pat ien ts that are 18 years of age or older.

Com m on Med icat ions

Lip itor

Nasonex

Many Others

Flonase

Ibuprofen 800 m g

Levaqu in

Albuterol

Alleg ra

Asthm a

Com m on Con d it ions

Pink Eye

Rashes

Sinus Cond it ions

Sore Throat

Stom ach Virus

Thyroid Cond it ions

Urinary Tract In fect ions

Yeast In fect ions

Ear Pain*

Fever

Gout

Headache

Hem orrhoids

High Blood Pressure

Join t Pain

Nausea

Acid Reflux

Allerg ies

Asthm a

Bladder In fect ion

Bronch it is

Cold & Flu

Const ipat ion

Cough

W h en t o Use TeleMed

WellVia doctors d iagnose acute, non-em ergent m ed ical cond it ions and prescribe m ed icat ions w hen clin ically appropriate.

Speak w ith a doctor anyt im e and pay no consu ltat ion fee rather than paying the h igh costs associated w ith off ice visit s, u rgent care visit s, and em ergency room visit s.

Just call 1-877-872-0370.

Dow n load t h e

W ellVia m ob ile app

In teg rated Care Managem entOn e conn ect ion for all you r clin ical n eeds. EMI Health has partnered w ith Magellan Rx Managem ent to support our m em bers th rough their w ellness journey. We offer a robust Health & Wellness Prog ram . Th is p rog ram w orks to ensure that m em bers w ith com plex m ed ical needs receive care in a cost effect ive and t im ely m anner.

How do w e do t h is?

Nurses, pharm acists, m ental health social w orkers, and w ellness coaches w ork together w ith in the sam e team to m ake sure the care, advice, and assistance you need is consisten t . Th is elim inates w asted t im e and decreases costs to both you and your p lan .

Personal Care

Th ink of an in teg rated team in th is w ay: you w on 't have to repeat your story to m ult ip le p rofessionals across d ifferen t d iscip lines because the Magellan Rx Managem ent team sit s together and w orks together so they are m ore aw are of you and your needs.

Keep healthy and en joy low ers costs th rough a healthy lifestyle and a resource to help you take advantage of your benef it s because w hen you are healthy, everyone is happy.

Sm art Cost Calcu latorKn ow you r cost s before you g o. EMI Health 's Sm art Cost Calcu lator allow s you to com pare d ifferen t p rocedures, p roviders, and hosp itals to see est im ated costs based on your search criteria.

*Change Healthcare is a cost t ransparency solu t ion the provides pricing in form at ion on som e m edical services and prescrip t ions. Th is in form at ion is in tended to be an est im ate of the total am ount you m ay expect to pay for the prescrip t ion or service, and is not guaranteed at the poin t of care.

1. Log in to your My EMI Health account .

2. Click t h e Sm art Cost Calcu lat or bu t t on .

3. Search for servicesEnter the doctor, hosp ital, or p rocedure you 're looking for.

4 . Com pare cost sSelect the doctor, hosp ital, or p rocedure to see review s, com pare costs, and get m ore details on w hat you need.

Here's h ow t o use it

Procedure Cost sSee data f rom local hosp itals and p roviders near you or search in a specif ied area. See how m uch specif ic p rocedures typ ically cost and your out of pocket expenses.

Provider Review sSearch for p roviders and see the review s their pat ien ts left . Th is tool helps ensure you are visit ing a p rovider that w ill m eet your needs.

Facil it y Locat ions an d Cost s Get hosp ital and clin ic d irect ions, pat ien t review s, and overall hosp ital rat ings so you visit t he p roper facilit y that w ill t ake care of your com plete healthcare situat ion .

Pharm acy, Mail Order & Retail 90Get a 90 -day supp ly of m ain t enan ce m ed icat ions at t h ree par t icipat in g pharm acies: Costco, Sam 's Club, and Walm art .

How Does t h e 90-Day Ret ail Fil l W ork ?

1. Ask your doctor for a p rescrip t ion for a 90-day supp ly (p lus ref ills, as app licab le).

2.Take your p rescrip t ion to a Costco, Sam ?s Club, or Walm art pharm acy.

3.You w ill pay th ree t im es the 30-day retail copaym ent for your p lan . The exact am ount you pay w ill depend on w hether your m ed icat ion is generic, p referred , or non-preferred b rand. Please refer to your Sum m ary of Benef it s for the details of your p lan .

How Does Mail Order W ork ?

1. Ask your doctor for a p rescrip t ion for a 90-day supp ly (p lus ref ills, as app licab le).

2. If you need to start t aking the m ed icat ion righ t aw ay, ask for another p rescrip t ion for up to a 30-day supp ly to be ref illed at a retail pharm acy.

3. Send the 90-day p rescrip t ion , along w ith the com pleted m ail-order form (w h ich can be dow nloaded f rom w w w.em ihealth .com ) and the appropriate copaym ent , to Express Scrip ts at the address on the form . (You m ay also ask your doctor to fax your order to Express Scrip ts)

4 . You w ill pay the Mail-order Copaym ent am ount ind icated on your Sum m ary of Benef it s. The exact am ount w ill depend on w hether your m ed icat ion is generic, p referred , or non-preferred b rand.

5. Express Scrip ts w ill p rocess the order and return it via U.S. Mail or UPS, along w ith inst ruct ions for fu ture ref ills. Allow up to 14 days for delivery f rom the t im e you m ail t he p rescrip t ion .

Not e

Plans enrolled in the Sm art 90 m ain tenance prog ram are not elig ib le for th is benef it .

Opioid DisposalEMI Heal t h t akes t h e op ioid cr isis very seriously,w hich is w hy it is im portan t to p roperly d ispose of op ioid m ed icat ions. Im proper d isposal of op ioid m ed icat ions can lead to add ict ion and suffering by others and harm fu l im pacts on the environm ent .

DON'T:

Give lef t over op ioids t o f r ien ds or fam ily. Most peop le add icted to op ioids get them f rom a fam ily m em ber. Do not be the source of their add ict ion .

Throw you r m ed icat ions in t h e t rash . Peop le can st ill accidentally or in tent ionally com e across these m edicat ions th rough your garbage.

Flush you r m ed icat ions dow n t h e sink or t o ilet . Flush ing op ioids dow n the sink or toilet can harm both the g roundwater and local w ild life.

DO:

Dispose of lef t over or exp ired op ioids. Keep ing leftover or exp ired op ioids around is dangerous to you and others w ho m ay com e across these m edicat ions.

Use a local Rx d rop box. These perm anent d rop sites are f ree and can be found at part icipat ing pharm acies and law enforcem ent agencies th roughout your state.

Find the nearest locat ion using the DEA's website here:

dead iverst ion .usdoj.gov/pubd ispsearch/

By t h e num bers

116 Am ericansd ie every day f rom op ioid overdose.

of all op ioid overdose deaths involve a

p rescrip t ion op ioid .

11.5 Mill ionm isused prescrip t ion op ioids in 2016.

40%

You CAN m ake a d if feren ce.

Help pu t a STOP t o t h e op ioid ep idem ic.

peop le

Sources:1. CDC/NCHS, Nat ional Vital Stat ist ics System s, Mortalit y. CDC Wonder, At lan ta, GA: US Departm ent of Health and Hum an Services, CDC;2017. Ht tps://w onder.cdc.gov.2. h t tp ://useon lyasd irected .org /th row -out /

fjj EXPRESS SCRIPTS' ��:MPIONS

·- BETTER" EM1f(HEALTH"

2019 Express Scripts National Preferred Formulary For EMI Health

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 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.

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 plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY

[INJ] - Injectable Drug Brand-name drugs are listed

in CAPITAL letters. Generic drugs are listed

in lower case letters.

BD AUTOSHIELD DUO NEEDLES

BD ULTRAFINE INSULIN SYRINGES

BD ULTRAFINE PEN NEEDLES BELBUCA benazepril

A benzonatate ------- BEPREVE ABILIFY MAINTENA [INJ] BETASERON [INJ] ABSORICA BETHKIS ACANYA BEVESPI AEROSPHERE acetaminophen/codeine BIKTARVY ACTEMRA [INJ] bisoprolol/hctz acyclovir blisovi fe AD EM PAS BOSULIF ADVAIR DISKUS BREO ELLIPTA ADVAIR HFA BRILINTA AFSTYLA [INJ] budesonide nebulization AIMOVIG [INJ] suspension AKYNZEO bupropion albuterol nebulization bupropion ext-release

solution buspirone alendronate butalbital/aceta m inophen/ allopurinol caffeine ALPHAGAN P 0.1 % BYDUREON [INJ] alprazolam BYETTA [INJ] ALREX SYSTOLIC amiodarone BYVALSON

clonidine clopidogrel clotrimazole/betamethasone

di propionate COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COPAXONE 40 MG [INJ] CORLANOR COSENTYX [INJ] CREON CRINONE cyanocobalamin [INJ] cyclobenzaprine

enalapril ENBREL [INJ] enoxaparin [INJ] ENSTILAR ENTRESTO EPCLUSA EPIDIOLEX EPIDUO FORTE epinephrine autoinjector

(by Mylan) [INJ] EPIPEN, EPIPEN JR [INJ] ergocalciferol ERIVEDGE ERLEADA ervthromycin eye ointment ESBRIET

D escitalopram --------- esomeprazole magnesium DALI RESP delayed-release DARAPRIM estradiol DAYTRANA estradiol patches DESCOVY estradiol/norethindrone desloratadine acetate desvenlafaxine succinate ESTRING

ext-release eszopiclone dexamethasone EUFLEXXA [INJ] DEXCOM RECEIVER, SENSOR, ezetimibe

TRANSMITTER ezetimibe/simvastatin dexmethylphenidate

ext-release F

GENOTROPIN [INJ] GENVOYA GILENYA GILOTRIF glimepiride glipizide glipizide ext-release GLUCAGEN [INJ] GLUCAGON [INJ] glyburide GLYXAMBI GONAL-F, GONAL-F RFF,

GONAL-F RFF REDI-JECT [INJ]

GRALISE GRANIX [INJ] GRASTEK guanfacine ext-release

H

HARVONI HELIXATE FS [INJ] HUMALOG [INJ] HUMIRA [INJ] HUMULIN [INJ] hydralazine hydrochloroth iazide hydrocodone/aceta mi nophen hydrocodone/ AMITIZA

amitriptyline amlodipine

C dextroamphetamine/ --------- chlorpheniramine polistirex

am lodipine/benazepril am lodipine/valsartan amoxicillin amoxicillin/potassium

clavulanate a nastrozole ANDRODERM ANORO ELLIPTA APRISO ARCAPTA NEOHALER ARIKAYCE aripiprazole ARISTADA [INJ] ARMONAIR RESPICLICK ARNUITY ELLIPTA ASMANEX HFA ASMANEX TWISTHALER atenolol atenolol/chlorthalidone atomoxetine atorvastatin AVONEX [INJ] AZASITE azelastine nasal spray azithromycin

B

baclofen BARACLUDE SOLUTION

--------- amphetamine famotidine CABOMETYX dextroamphetamine/ FARXIGA CANASA amphetamine ext-release fenofibrate CARAC diazepam fenofibrate micronized CARAFATE SUSPENSION diclofenac sodium fenofibric acid carbidopa/levodopa delayed-release delayed-release carvedilol dicyclomine fentanyl patches cefdinir digoxin FETZIMA cefuroxime axetil diltiazem ext-release FINACEA FOAM celecoxib diphenoxylate/atropine finasteride cephalexin divalproex delayed-release FIRAZYR [INJ] CERDELGA divalproex ext-release FLECTOR CEREZYME [INJ] DIVIGEL FLOVENT DISKUS CETROTIDE [INJ] donepezil FLOVENT HFA CHANTIX doxazosin fluconazole chlorhexidine gluconate doxycycline hyclate fluocinonide chlorthalidone doxycycline monohydrate fluoxetine CIMDUO DUAVEE fluticasone nasal spray CIPRODEX DULERA folic acid ciprofloxacin duloxetine delayed-release FORTEO [INJ] citalopram DUPIXENT [INJ] FRAGMIN [INJ] clarithromycin DYMISTA FREESTYLE LIBRE READER, CLENPIQ SENSOR clindamycin hcl f furosemide clindamycin phosphate -------- FYCOMPA

topical EDARBI clindamycin phosphate/ EDARBYCLOR G

benzoyl peroxide ELIDEL clobetasol propionate ELIQUIS gabapentin clomiphene citrate EMGALITY [INJ] GELNIQUE clonazepam EMVERM gemfibrozil

ext-release hydrocortisone topical hydromorphone hydroxychloroq uine hydroxyzine hcl hydroxyzine pamoate HYSINGLA ER

I

ibandronate IBRANCE ibuprofen ILEVRO INCRUSE ELLIPTA indomethacin INLYTA INVOKAMET INVOKAMET XR INVOKANA irbesartan IRESSA isosorbide mononitrate

ext -release

J

JANUMET, JANUMET XR JANUVIA JARDIANCE JENTADUETO

(continued)

Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary.

THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com.

© 2019 Express Scripts. All Rights Reseried. All trademarks are the property of their respective owners.

2477, 2478 NP-A PRMTEMIANP-19 (01/01/19)

JENTADUETO XR JIVI [INJJ junel junel fe

MONOVISC [INJ] montelukast

p ropinirole -------- rosuvastatin

morphine sulfate ext-release pantoprazole delayed-release MOVANTIK paroxetine hcl MOXEZA PAZEO

RUCONEST [INJ]

s

TRESIBA [INJJ triamcinolone topical triamterene/hctz tri-lo-marzia trinessa

K moxifloxacin eye solution penicillin v potassium ------- TRIPTODUR [INJ] -------- mupirocin PENTASA ketoconazole topical MUSE PERFOROMIST ketorolac MYDAYIS PHOSLYRA KITABIS PAK MYRBETRIQ PICATO KOGENATE FS [INJ] pioglitazone KOVALTRY [INJ] N PLEGRIDY [INJ]

SANCUSO SAVELLA SEGLUROMET SEREVENT DISKUS sertraline SIMPON! 100 MG (for

tri-spri ntec TRULANCE TRULICITY [INJ] TUDORZA PRESSAIR TYMLOS [INJJ

KYLEENA -------- polymyxin/trimethoprim ulcerative colitis only) [INJ] U nabumetone eye solution simvastatin --------

L NAMZARIC POMALYST SKYLA -------- naproxen, naproxen sodium potassium chloride SOLIQUA [INJ] labetalol lamotrigine lansoprazole delayed-release LANTUS [INJ] latanoprost eye solution LATUDA LETAIRIS LEVEMIR [INJ] levetiracetam levoceti rizine levofloxacin levothyroxine sodium lidocaine patches LINZESS liothyronine LIPOFEN lisinopril lisinopril/hctz LIVALO LO LOESTRIN FE LOKELMA lorazepam losartan

neomycin/polymyxin/ ext-release hydrocortisone ear solution PRALUENT [INJ]

NEXIUM PACKETS pramipexole niacin ext-release pravastatin nifedipine ext-release prednisolone acetate nitrofurantoin macrocrystal eye suspension NITYR prednisolone sodium NORDITROPIN [INJ] phosphate nortriptyline prednisone NOVAREL [INJ] PREMARIN CREAM NOVOEIGHT [INJ] PREMARIN TABLETS NOVOFINE AUTOSHIELD PREMPHASE

NEEDLES PREM PRO NOVOFINE NEEDLES PREPOPIK NOVOTWIST NEEDLES PROAIR HFA NUCALA [INJ] PROAIR RESPICLICK NUCYNTA, NUCYNTA ER PROCRIT [INJ] NUEDEXTA progesterone micronized NUVARING PROLASTIN C [INJ] NUWIQ [INJ] PROLENSA nystatin promethazine nystatin topical promethazine/

SOLODYN SOMATULINE DEPOT [INJ] SOOLANTRA SPIRIVA RESPIMAT spironolactone sprintec SPRYCEL STEGLATRO STELARA SC [INJ] STIOLTO RESPIMAT STRENSIQ [INJ] STRIVERDI RESPIMAT SUBOXONE SL FILM sulfamethoxazole/

trimethoprim sumatriptan SUPREP SUTENT SYMBICORT SYMFI SYMFI LO SYMLINPEN [INJ] SYMPROIC dextromethorphan

propranolol -------- propranolol ext-release

losartan/hctz 0 LOTEMAX

SYNJARDY, SYNJARDY XR

lovastatin ODACTRA LUM I GAN OFEV LYRICA ofloxacin

olanzapine M olmesartan -------- olmesartan/hctz meclizine medroxyprogesterone meloxicam MESTINON SYRUP metaxalone metformin metformin ext-release methimazole methocarba mol methotrexate methylphenidate methylphenidate ext-release methylpredn isolone metoclopramide metoprolol succinate

ext-release metoprolol tartrate metronidazole metronidazole topical metronidazole vaginal microgestin fe MINIVELLE minocycline MIRENA mirtazapine MIRVASO MITIGARE moderiba mometasone

olopatadine eye solution omega-3 acid ethyl esters omeprazole delayed-release ondansetron ondansetron orally

disintegrating tablets ONETOUCH KITS/METERS;

ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC

ONETOUCH TEST STRIPS; ULTRA, VERIO

ONEXTON OPSUMIT ORACEA ORFADIN ORTHOVISC [INJ] oseltamivir OTEZLA OTOVEL OTREXUP [INJ] OVIDREL [INJ] oxcarbazepine oxybutynin ext-release oxycodone oxycodone/aceta mi nophen OXYCONTIN OZEMPIC [INJ]

PULMICORT FLEXHALER T PYLERA

TACLONEX SUSPENSION Q tacrolimus topical �------- tamoxifen QBREXZA tamsulosin ext-release QNASL TARCEVA QUDEXY XR TASIGNA quetiapine TAYTULLA QUILLICHEW ER TAZORAC GEL QUILLIVANT XR TAZORAC 0.05% CREAM guinapril TECFIDERA QVAR TEKTURNA, TEKTURNA HGT QVAR REDIHALER terazosin

terconazole vaginal R testosterone cypionate [INJJ -------- THALOMID rabeprazole delayed-release RAGWITEK raloxifene ramipril RANEXA ranitidine RAPAFLO RASUVO [INJ] REBIF [INJ] RECTIV RELISTOR [INJ] REMICADE [INJ] RESTASIS RETACRIT [INJ] REVLIMID RHO PR ESSA risperidone rizatriptan

timolol maleate eye solution tizanidine TOBI PODHALER TOBRADEX OINTMENT TOBRADEX ST tobramycin eye solution tobramycin/dexamethasone

eye suspension topiramate TOUJEO [INJ] TOVIAZ TRACLEER TRADJENTA tramadol TRAVATAN Z trazodone TRELEGY ELLIPTA TREMFYA [INJ]

UCERIS FOAM ULORIC UPTRAVI

V

valacyclovir valsartan valsartan/hctz VARUBI VASCEPA VELPHORO VELTASSA venlafaxine venlafaxine ext-release VENTOLIN HFA verapamil ext-release VESICARE VIBERZI VIIBRYD VIMPAT VIOKACE VOSEVI VYVANSE

w

warfarin

X

XALKORI XARELTO XELJANZ, XELJANZ XR XIFAXAN XIGDUO XR XIIDRA XOFLUZA XOLAIR [INJ] XTANDI XULTOPHY [INJ]

y

YONSA yuvafem

z

ZARXIO [INJ] ZENPEP ZEPATIER zolpidem zolpidem ext-release ZOMIG NASAL ZONTIVITY ZOVIRAX CREAM ZTLIDO ZUBSOLV ZYLET ZYTIGA

Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary.

THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TD CHANGE. You can find more information at express-scripts.com.

© 2019 Express Scripts. All Rights Reser1ed. All trademarks are the property of their respective owners.

2477, 2478 NP-A PRMTEMIANP-19 (01/01/19)

fl, EXPRESS SCRIPTS•·-

CHAMPIONS FOR BETTER'"

2019 EMI Health Preferred Drug List Exclusions The excluded medications shown below are not covered on the EMI Health drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price.

Take action to avoid paying full price. If you're currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card.

Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund.

Drug Class Excluded Medications

AUTONOMIC & CENTRAL NERVOUS SYSTEM LUCEMYRA

Alpha-2 Adrenergic Agonists (for Opioid Withdrawal)

Anti-Migraine Therapy SUMAVEL DOSEPRO

GOCOVRI ER, OSMOLEX ER Antiparkinsonism Agents

XADAGO

Beta Interferons for Multiple Sclerosis EXTAVIA

Calcitonin Gene-Related Peptide Antagonists AJOVY

EMFLAZA Duchenne Muscular Dystrophy (DMD) Agents

EXONDYS 51

Long-Acting Opioid Oral Analgesics EMBEDA,OXYCODONE ER

Narcotic Analgesics BUTRANS

Neuropathic Agents LYRICA CR

Transmucosal Fentanyl Analgesics ABSTRAL, FENTORA, LAZANDA

CARDIOVASCULAR PRADAXA, SAVAYSA

Anticoagulants

Beta Blockers KAPSPARGO SPRINKLE

HMG & Cholesterol Inhibitor Combinations ALTOPREV, ZYPITAMAG

PCSK9 Inhibitors REPATHA

DERMATOLOGICAL MINOCYCLINE ER 55 MG TABLETS, MINOLIRA

Oral Agents for Acne

Oral Agents for Rosacea DOXYCYCLINE 40 MG CAPSULES

Topical Acne PLIXDA

Topical Acne/Antibiotic Combinations AKTIPAK, VELTIN

FLUOROURACIL 0.5% CREAM, Topical Agents for Actinic Keratosis

IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA

Topical Antifungals LULICONAZOLE

Topical Antiviral Agents XERESE CREAM

Topical Corticosteroids TOPICORT SPRAY, VERDESO FOAM

Miscellaneous Topical Dermatological Agents ALCORTIN A

© 2018 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Preferred Alternatives

clonidine

sumatriptan injection

amantadine capsules, amantadine tablets, amantadine oral solution

rasagiline, selegiline

AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, PLEGRIDY, REBIF, REBIF REBIDOSE

AIMOVIG, EMGALITY

prednisone solution, prednisone tablets

No alternatives recommended

hydromorphone ER, morphine sulfate ER, oxymorphone ER, HYSINGLA ER, NUCYNTA ER, OXYCONTIN

BELBUCA

gabapentin, GRALISE, LYRICA

fentanyl citrate lozenges

ELIQUIS, XARELTO

metoprolol succinate

atorvastatin, lovastatin, rosuvastatin, simvastatin, LIVALO

PRALUENT

minocycline ER

ORACEA

adapalene

clindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, ACANYA, ONEXTON

diclofenac 3% gel, fluorouracil 2% solution, fluorouracil 5% cream, imiquimod 5% cream, CARAC, PICATO

ciclopirox, econazole, ketoconazole, naftifine, oxiconazole

acyclovir capsules, acyclovir tablets, famciclovir tablets, valacyclovir tablets, ZOVIRAX CREAM

desonide 0.05% cream/lotion/ointment, desoximetasone 0.25% cream/ointment

hydrocortisone, mupirocin

Continued

2477, 2478 0L44109Q-EMl· 19 (12/05/2018)

Drug Class

DIABETES

Blood Glucose Meters & Test Strips

Dipeptidyl Peptidase-4 Inhibitors & Combinations

Glucagon-Like Peptide-1 Agonists

Insulins

EAR/NDSE

Nasal Steroids

Otic Fluoroquinolone Antibiotics

ENDOCRINE (OTHER)

Combination Patches

Estrogen and Estrogen Modifiers for Vaginal Symptoms

Gonadotropin Releasing Hormone (GnRH) Agonists

(for Central Precocious Puberty)

Growth Hormones

Somatostatin Analogs

Topical Estrogen Gels

GASTROINTESTINAL

Corticosteroids (Rectal Formulations)

Inflammatory Bowel Agents

Pancreatic Enzymes

Proton Pump Inhibitors

HEMATOLOGICAL

Erythropoiesis-Stimulating Agents

Factor VIII Recombinant Products

Granulocyte Colony Stimulating Factors

HEPATITIS

Hepatitis C

HIV

Antiretrovirals

MUSCULOSKELETAL & RHEUMATOLOGY

Gout Therapy

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

OBSTETRICAL & GYNECOLOGICAL

Gonadotropin-Releasing Hormone (GnRH)

Antagonists (for Infertility)

© 2018 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Excluded Medications

ABBOTT (FREESTYLE, PRECISION), BAYER (BREEZE,

CONTOUR), NATIONAL MEDICAL (ADVOCATE), OMNIS

HEALTH (EMBRACE, VICTORY), ROCHE (ACCU-CHEK),

TRIVIDIA (TRUETEST, TRUETRACK), UNISTRIP

ALL OTHER METERS & STRIPS THAT ARE NOT LIFESCAN BRAND

ALOGLIPTIN, NESINA, ONGLYZA

ALOGLIPTIN/METFORMIN, KAZANO, KOMBIGLYZE XR

ADLYXIN, TANZEUM, VICTOZA

NOVOLIN

ADMELOG, APIDRA, FIASP, NOVOLOG

BECONASE AQ, OMNARIS, ZETONNA

CETRAXAL

CLIMARA PRO

FEMRING

LUPRON DEPOT-PED

HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE,

SAIZEN, SAIZENPREP, ZOMACTON

SANDOSTATIN LAR DEPOT, SIGNIFOR LAR

ESTROGEL

CORTIFOAM

DELZICOL, DIPENTUM

PANCREAZE,PERTZYE

ACIPHEX SPRINKLE, PRILOSEC SUSPENSION,

PROTONIX SUSPENSION

ARANESP, EPOGEN, MIRCERA

ELOCTATE, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE

NEUPOGEN, NIVESTYM

DAKLINZA, LEDIPASVIR/SOFOSBUVIR, MAVYRET, OLYSIO,

SOFOSBUVIRNELPATASVIR, SOVALDI

ATRIPLA, DELSTRIGO, SYMTUZA

PIFELTRO

COLCHICINE

DUZALLO, ZURAMPIC

FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES

GANIRELIX ACETATE

Preferred Alternatives

LIFESCAN (ONETOUCH)

JANUVIA, TRADJENTA

JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

BYDUREON, BYETTA, OZEMPIC, TRULICITY

HUMULIN

HUMALOG

budesonide, flunisolide, fluticasone, mometasone, QNASL

ciprofloxacin ear solution, ofloxacin ear solution,

CIPRODEX, OTOVEL

COMBIPATCH

estradiol patches, estradiol tablets, yuvafem,

ESTRING, PREMARIN CREAM, PREMARIN TABLETS

TRIPTODUR

GENOTROPIN, NORDITROPIN FLEXPRO

SOMATULINE DEPOT

DIVIGEL

hydrocortisone enema, UCERIS FOAM

balsalazide disodium, mesalamine 1.2 gm delayed release,

sulfasalazine, APRISO, PENTASA

CREON,ZENPEP

esomeprazole, lansoprazole, omeprazole, pantoprazole,

rabeprazole, NEXIUM PACKETS

PROCRIT, RETACRIT

ADVATE, ADYNOVATE, AFSTYLA, HELIXATE FS, JIVI,

KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ

GRANIX, ZARXIO

EPCLUSA, HARVONI, VOSEVI, ZEPATIER

BIKTARVY, GENVOYA, ODEFSEY, STRIBILD, SYMFI, SYMFI LO,

TRIUMEQ

efavirenz, nevirapine ER, EDURANT, INTELENCE, RESCRIPTOR

COLCRYS, MITIGARE

allopurinol, probenecid

fenoprofen calcium tablets, diclofenac, ibuprofen,

indomethacin, meloxicam, nabumetone, naproxen

CETROTIDE

Continued

2477, 2478 0L44109Q-EMl-19 (12/05/2018)

Drug Class

OBSTETRICAL & GYNECOLOGICAL (continued)

Gonadotropin-Releasing Hormone (GnRH)

Receptor Antagonists (for Endometriosis)

Human Chorionic Gonadotropin

Ovulatory Stimulants (Follitropins)

Vaginal Progesterones

OPHTHALMIC

Antiglaucoma Drugs (Beta-Adrenergic Blockers)

Antiglaucoma Drugs (Ophthalmic Prostaglandins)

Ophthalmic Anti-Allergic

Ophthalmic Anti-Inflammatory

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs

(NSAIDs)

OSTEOARTHRITIS

Hyaluronic Acid Derivatives

RENAL DISEASE

Phosphate Binders

RESPIRATORY

Epinephrine Auto-Injector Systems

Long-Acting Beta Agonist Nebulized

Pulmonary Anti-Inflammatory Inhalers

Short-Acting Beta2-Agonist Inhalers

MISCELLANEOUS AGENTS

Hereditary Angioedem a

Polyneuropathy of Hereditary

Transthyretin-Mediated Amyloidosis

Drug Class

INFLAMMATORY CONDITIONS:!:

Excluded Medications

ORILISSA

CHORIONIC GONADOTROPIN, PREGNYL

BRAVELLE, FOLLISTIM AQ

ENDOMETRIN

TIMOPTIC OCUDOSE

ZIOPTAN

ALOCRIL, ALOMIDE, EMADINE

FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD

ACUVAIL, NEVANAC

DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN,

HYMOVIS, SUPARTZ FX, SYNVISC, SYNVISC-ONE, TRIVISC,

VISC0-3

FOSRENOL POWDER PACKETS, RENAGEL

AUVI-Q, EPINEPHRINE AUTO-INJECTOR

(BY A-S MEDICATION, IMPAX & LINEAGE)

BROVANA

ALVESCO

LEVALBUTEROL HFA, PROVENTIL HFA, XOPENEX HFA

HYDROXYPROGESTERONE 1,250 MG/5 ML

SIKLOS

NOCTIVA

BERINERT

ONPATTRO

Indication Based Management

Nonpreferred Medications

All other Brand Name medications for Inflammatory

Conditions are Nonpreferred. Approval may be granted

following a coverage review. A trial of one or more Preferred

medications is required prior to initiating therapy with a

Non preferred medication. A formulary exception may be

granted for patients already established on therapy with a

Nonpreferred medication.

Preferred Alternatives

LUPRON DEPOT, SYNAREL, ZOLADEX

NOVAREL, OVIDREL

GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT

CRINONE 8% GEL

betaxolol drops, levobunolol drops, timolol drops,

ALPHAGAN P 0.1 %, COMBIGAN

bimatoprost drops, latanoprost drops, LUMIGAN, TRAVATAN Z

azelastine drops, cromolyn drops, olopatadine drops,

ALREX,BEPREVE,PAZEO

dexamethasone drops, fluorometholone drops,

prednisolone drops, LOTEMAX

bromfenac drops, diclofenac drops, ketorolac drops,

ILEVRO, PROLENSA

EUFLEXXA, MONOVISC, ORTHOVISC

lanthanum, sevelamer carbonate, PHOSLYRA, VELPHORO

EPINEPHRINE AUTO-INJECTOR (BY MYLAN),

EPIPEN, EPIPEN JR

PERFOROMIST

ARMONAIR RESPICLICK, ARNUITY ELLIPTA,

ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA,

PULMICORT FLEXHALER, QVAR

PROAIR HFA/RESPICLICK, VENTOLIN HFA

hydroxyprogesterone caproate 250 mg/ml (single dose vial)

DROXIA

desmopressin tablets

RUCONEST

No alternatives recommended

Preferred Alternatives

ACTEMRA, COSENTYX, ENBREL, HUMIRA,

INFLECTRA, OTEZLA, REMICADE, RENFLEXIS,

SIMPONI 100 MG (FOR ULCERATIVE COLITIS ONLY),

STELARA SC, TREMFYA*, XEUANZ, XEUANZ XR

:f: Please note that product placement for treatment for Inflammatory Conditions are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches.

* This medication may be subject to step therapy.

© 2018 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Continued

2477, 2478 0L44109Q-EMl-19 (12/05/2018)

ABBOTT (FREESTYLE, PRECISION) ABILIFY" ABSTRAL ACIPHEX" ACIPHEX SPRINKLE ACUVAIL ADCIRCA" ADDERALL" ADLYXIN ADMELOG AJOVY AKTIPAK ALCORTIN A ALOCRIL ALOGLIPTIN ALOGLIPTIN/METFORMIN ALOMIDE ALTOPREV ALVESCO ANDROGEL 1 % " ANUSOL-HC" APIDRA ARANESP ARI MID EX" ASACOL HD" ATACAND", ATACAND HCT" ATRIPLA AUVI-Q AVALIDE", AVAPRO" AVODART" AZOR" BAYER (BREEZE, CONTOUR) BECONASE AQ BEN I CAR", BEN I CAR HCT" BERINERT BRAVELLE BRISDELLE" BROVANA BUPAP" BUTRANS CELEBREX" CELEXA" CETRAXAL CHORIONIC GONADOTROPIN CLIMARA PRO COLCHICINE COREG" CORTIFOAM COSOPT" COZAAR", HYZAAR" CRESTOR" CYMBALTA" CYTOMEL" DAKLINZA DELSTRIGO DELZICOL DETROL ", DETROL LA" DIOVAN", DIOVAN HCT" DIPENTUM DOXYCYCLINE 40 MG CAPSULES DUROLANE DUZALLO EFFEXOR XR" ELOCTATE EMADINE EMBEDA EMFLAZA ENDOMETRIN EPINEPHRINE AUTO-INJECTOR

(BY A-S MEDICATION, IMPAX & LINEAGE) EPOGEN ESTROGEL EXFORGE", EXFORGE HCT" EXONDYS 51 EXTAVIA FEMRING FENOPROFEN CAPSULES FENORTHO FENTORA FIASP

Excluded Medications/Products at a Glance

FLAREX FLUOROURACIL 0.5% CREAM FML FORTE, FML S.O.P. FOLLISTIM AQ FOSRENOL CHEWABLE TABLETS" FOSRENOL POWDER PACKETS GANIRELIX ACETATE GEL-ONE GELSYN-3 GENVISC 850 GLEEVEC" GLUCOPHAGE",GLUCOPHAGE XR" GLUMETZA" GOCOVRI ER HUMATROPE HYALGAN HYDROXYPROGESTERONE 1,250 MG/5 ML HYMOVIS IMIQUIMOD 3.75% CREAM PUMP IMITREX" INDERAL LA" INTUNIV" ISTALOL" KAPSPARGO SPRINKLE KAZANO KEPPRA", KEPPRA XR" KOMBIGLYZE XR LAMICTAL ", LAMICTAL ODT", LAMICTAL XR" LAZANDA LEDIPASVIR/SOFOSBUVIR LEVALBUTEROL HFA LEXAPRO" LIBRAX" LIDODERM" LIPITOR" LOESTRIN", LOESTRIN FE" LOTREL" LOVENOX" LUCEMYRA LULICONAZOLE LUNESTA" LUPRON DEPOT-PED LYRICA CR MAVYRET MAXALT", MAXALT MLT" MAXIDEX MICARDIS", MICARDIS HCT" MINASTRIN 24 FE" MINOCYCLINE ER 55 MG TABLETS MINOLIRA MIRCERA NALFON CAPSULES NAMENDA XR" NASONEX" NATIONAL MEDICAL (ADVOCATE) NESINA NEUPOGEN NEURONTIN" NEVANAC NIVESTYM NOCTIVA NORCO" NORVASC" NOVOLIN NOVOLOG NUTROPIN AQ NUSPIN NUVIGIL" OLYSIO OMNARIS OMNIS HEALTH (EMBRACE, VICTORY) OMNITROPE ONGLYZA ONPATTRO ORILISSA ORTHO TRI-CYCLEN", ORTHO TRI-CYCLEN LO" OSMOLEX ER OXYCODONE ER PANCREAZE PERTZYE PIFELTRO

PLAQUENIL" PLAVIX" PLIXDA PRADAXA PRED MILD PREGNYL PREVACID", PREVACID SOLUTAB" PRILOSEC SUSPENSION PRISTIQ" PROTONIX" PROTONIX SUSPENSION PROVENTIL HFA PROVIGIL" PROZAC" PULMICORT RESPULES" RECOMBINATE RENAGEL REPATHA ROCHE (ACCU-CHEK) SAIZEN, SAIZENPREP SANDOSTATIN LAR DEPOT SAVAYSA SEROQUEL",SEROQUEL XR" SIGNIFOR LAR SIKLOS SINGULAIR" SOFOSBUVIRNELPATASVIR SOVALDI STRATTERA" SUMAVEL DOSEPRO SUPARTZ FX SYMTUZA SYNVISC, SYNVISC-ONE TANZEUM TESTIM" TIKOSYN" TIMOPTIC OCUDOSE TOBI SOLUTION" TOPAMAX" TOPICORT SPRAY TRIBENZOR" TRICOR" TRILEPTAL" TRIVIDIA (TRUETEST, TRUETRACK) TRIVISC UNISTRIP UROXATRAL" VAGIFEM" VALIUM" VALTREX" VELTIN VERDESO FOAM VICTOZA VISC0-3 VIVELLE-DOT" VYTORIN" WELLBUTRIN SR" XADAGO XALATAN" XANAX", XANAX XR" XENAZINE" XERESE CREAM XOPENEX HFA XYNTHA, XYNTHA SOLOFUSE YASMIN" ZEGERID" ZETIA" ZETONNA ZIOPTAN ZOCOR" ZOLOFT" ZOMACTON ZOMIG TABLETS", ZOMIG ZMT" ZONEGRAN" ZURAMPIC ZYCLARA ZYFLO CR" ZYPITAMAG

11 Multisource brand exclusion - The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain thesame active ingredients as their corresponding brand-name medications, although they may have a different appearance. As new generic medications become available, additional multisource brand products may become excluded.

© 2018 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

2477, 2478 0L44109Q-EMl-19 (12/05/2018)

Utah Hosp ital Netw orkAn expansive n et w ork t o care for you , w h erever you are.

Sal t Lake Coun t y

TOSH - The Orthoped icSpecialty Hosp ital

Logan Reg ional Hosp ital

Dixie Reg ional Med ical Center

Bear River Valley Hosp ital

McKay Dee Hosp ital

Davis Hosp ital & Med ical Center

Layton Hosp ital

Park City Hosp italMountain West Med ical Center

Am erican Fork Hosp ital

Heber Valley Hosp italAsh ley ValleyMed ical Center

Prim ary Ch ild ren 's Hosp ital

LDS Hosp ital

In term ountainMed ical Center

Riverton Hosp ital

Alta View Hosp ital

John A. MoranEye Center

U of U Hosp italBurn Center

Orem Com m unity Hosp ital

Utah Valley Hosp ital

Cast leview Hosp italCent ral Valley Med ical Center

Uin tah Basin Med ical Center

Sanpete Valley Hosp ital

Gunn ison Valley Hosp ital

Sevier Valley Hosp ital

Moab Reg ionalHosp ital

San Juan Hosp italBeaver Valley Hosp ital

Delta Com m unity Hosp ital

Fillm ore Com m unity Hosp ital

M ilford Mem orial Hosp ital

Cedar City Hosp ital Garf ield Mem orial Hosp ital

Blue Mountain Hosp ital

Kane County Hosp ital

Huntsm an In term ountain Cancer Center located at th is facilit y

In term ountain Healthcare Ow ned Hosp ital

In term ountain InstaCare & KidsCareSMSM

Cedar City InstaCare

Sunset InstaCare Hurricane Valley InstaCare

River Road InstaCare

Sal t Lake Coun t y

Alta View InstaCare/KidsCare

North Cache Valley InstaCare

Logan InstaCare

Box Elder InstaCare

South Ogden InstaCareHerefordsh ire InstaCare

Park City InstaCare

Layton Parkw ay InstaCare

Am erican Fork InstaCare

Heber Valley InstaCare

Holladay InstaCareSalt Lake Clin ic InstaCare

West Valley InstaCare

Southridge InstaCare/KidsCare

Draper InstaCare

Cot tonw ood InstaCare

Mem orial InstaCare/KidsCare

North Orem InstaCareProvo InstaCare

North Ogden InstaCare

Bount ifu l InstaCare/KidsCare

Tooele InstaCare

Taylorsville InstaCare/KidsCare

West Jordan InstaCare/KidsCare

Saratoga Springs InstaCare

Springville InstaCare

Payson InstaCare

Leh i InstaCare

SOUTHERN UTAH UNIVERSITY

MEDICAL PLAN EXCLUSIONS 2019

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’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 Out-of-Pocket 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 Member is entitled to have paid or obtain without cost, in accordance with the laws of

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.

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 will be 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 1998.

27. 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

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 http://bit.ly/USPSTF_AB.)

31. 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

http://bit.ly/USPSTF_AB).

33. 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 disorders, intellectual disabilities, 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 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

voluntarily 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. Infertility services including, but not limited to, the following. This exclusion does not

apply to the initial assessment and diagnosis of the condition.

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.

43. The Adoption Indemnity Benefit (see Additional Benefit section) in connection with the

adoption of any child over 90 days of age.

44. The reversal of a surgically performed sterilization, subsequent sterilization, or ovulation-

inducing drugs or injections.

45. 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.

46. Care, treatment, or surgical procedures for erectile dysfunction.

47. Care, treatment, or devices to aid in female sexual arousal disorder including, but not

limited to, Eros Clitoral Therapy Device.

48. Expenses in connection with a penile prosthesis.

49. All organ Transplant services when rendered by Non-participating Providers.

50. 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.

51. Repair or replacement of any otherwise covered Implant when rendered by Non-

participating Providers.

52. Expenses for and in connection with artificial hearts.

53. 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, insulin infusion pumps, or

intrathecal pumps.

54. Charges for Durable Medical Equipment, medical supplies, medication, or lab tests that

are purchased via the internet from Non-participating Providers or vendors, or for which

a prescription or physician order is not required.

55. 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.

56. 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.

57. Radial keratotomy or lamellar keratectomy, or other eye surgery performed primarily to

correct refractive errors.

58. 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)

Removal of impacted teeth

59. 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 or who has a medical

condition that makes dental anesthesia Medically Necessary.

60. 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.

61. Expenses in connection with speech therapy, other than rehabilitation that is Medically

Necessary to restore and improve function that was previously normal but was lost

following a documented injury or Illness.

62. Expenses for whole blood, or blood derivatives.

63. Care, treatment, or services involving acupuncture, acupressure, dry needling, or

hypnosis.

64. 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.

65. 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.

66. Care, treatment, or services including, but not limited to, testing associated with

autogenous urine immunization, sublingual provocation, leukocytoxicity, and

subcutaneous provocation and neutralizing.

67. Expenses in connection with herbal, holistic, or homeopathic treatment, or for

complications thereof.

68. Food supplements including vitamins, minerals, and herbs, plus enteral nutrition

products, formulas, and medical food that are administered orally and any related

supplies.

69. Genetic, molecular, or gene-based testing except for tests on the Plan’s approved list and

when the Covered Person meets the specific criteria. Genetic counseling unless required

by the Affordable Care Act.

70. Expenses for gene therapy, adoptive immunotherapy, and cellular therapy.

71. 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.

72. 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. The Plan retains authority to

limit benefit availability to Providers of inter-facility air transport if and when a

Provider fails to comply with the terms of the Plan or billed charges exceed the

Maximum Allowable Charge in accordance with the terms of the Plan.

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.

73. 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, unless billed by a Home Health agency.

Home Health aides or services.

74. 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.

75. Expenses for appointments scheduled but not kept.

76. Expenses for telephone consultations or services delivered remotely via email or other

telecommunication technologies, except as specifically provided under a telemedicine

benefit. This exclusion does not apply to covered telehealth consultative services

provided within a participating facility or clinic.

77. Care, treatment, or services rendered by any Provider who ordinarily resides in the same

household (e.g. Spouse, parent).

78. Services performed by a Provider that is not covered by the Plan including, but not

limited to, the following:

Acupuncturist

Doctor of education

Clergy

Home Health aide

Nurse’s aide

Hygienist

Hypnotist

Medical assistant

Massage therapist

Naturopath

Vocational nurse

Personal fitness trainer/coach

Non-physician technician

Birthing centers

79. All self-administered Injectables. 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)

80. All medications that are excluded under the “Drug Program” are also excluded under

Medical. This exclusion does not apply to the following (under Medical plan):

Chemotherapeutic 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 enteral feeding when administered via nasogastric,

gastrotomy, or jejunostomy tube.

81. All services, equipment, and supplies provided or ordered to treat complications or

Secondary Medical Conditions that arise as a direct result of a non-covered Illness,

injury, condition, situation, procedure, or treatment.

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