Medical Plans

PEHP offers two types of health plans: Traditional and High-Deductible Health Plans (HDHP), such as the STAR HSA Plan. Your plan outlines the terms of your medical coverage and cost sharing agreement (copays, deductibles, out-of-pocket maximums) for in-network and out-of-network services.

Here’s a snapshot of both types of medical plans:

Traditional Plan

• Higher premium than HDHP. Premium is what you pay to have health insurance. This amount is deducted from your paycheck whether you go to the doctor or not.
• Copays apply for office and doctor visits. Copays go towards your Maximum Out-of-Pocket (MOOP) but not towards your deductible.
• Your total out of pocket costs would be the deductible + OOPM. Note: Each family member has their own deductible and MOOP.
• You can enroll in a Flexible Spending Account (FSA) or Dependent Care FSA to set aside money for healthcare or dependent daycare costs with pre-tax money. Note that FSA funds are use it or lose it at the end of the calendar year. Depending on your employer, you may be able to rollover a certain amount for the next year. FSA amounts are set by the IRS every year.

HDHP (such as STAR HSA Plan)

• Lower premium or no premium - This means you keep more money in your paycheck and only pay for healthcare when you need it!
• Higher deductible, but the amount counts towards a combined family Maximum Out-of-Pocket (MOOP).
• You can enroll in a Health Savings Account (HSA) to set aside pre-tax money to help with healthcare costs. Your employer can help fund your HSA and you can also contribute funds up to the IRS limits. You never lose funds in your HSA – funds rollover every year.

When it comes to disease prevention, getting health screenings and immunizations is important. You can get annual preventive care services at No Cost when you visit an in-network provider - no copay, coinsurance, or deductible. PEHP covers 100% of the cost for preventive care services based on specific eligibility criteria.

Stay healthy and protect others. The flu and COVID vaccines are covered at no cost to you when you visit a contracted provider. See a list of all preventive care benefits. The Centers for Disease Control and Prevention (CDC) recommends the updated COVID-19 vaccine for everyone 6 months of age and older. Learn more.

Top Places to Get Immunizations

1. Flu clinic offered at your worksite. (Check with your employer)
2. Your local pharmacy – can't beat the convenience.
3. Your doctor's office – combine with a scheduled visit.
4. Health department – call for more details.

Please call PEHP (801-366-7555) for information about which autism spectrum disorders and services are covered. Not all employers offer this benefit. If you have this benefit, below is a brief summary of coverage:

• Therapeutic care includes services provided by speech therapists, occupational therapists, or physical therapists.
• Eligible Autism Spectrum Disorder services do not accrue separately, and are subject to the medical plan’s visit limits, regular cost sharing limitations – deductibles, co-payments, and coinsurance – and would apply to the out-of-pocket maximum.
• Mental health and speech therapy services require preauthorization.
• No benefits for services received from out-of-network providers. See a list of in-network providers in the PEHP Provider Directory.
• Regular medical benefits will apply (see benefits grid for applicable co-pay and coinsurance).

If you are interested in gender dysphoria benefits, please contact PEHP at 801-366-7555 to inquire about specific coverage available to you.

• Your child is eligible to stay on your medical coverage until age 26, even if married or not living at home.
• Duplicate PEHP identification cards are available or can be printed for your child.
• Your subscriber ID number will remain on the card.
• Your dependent can create their own PEHP account.

• We need the out-of-state or out-of-country address of your child. Please call us at 801-366-7755 or send us a message through the Message Center when you log in to your PEHP account.
• Use the Out-of-State network to find in-network providers and avoid balance billing.
• You can compare plans that are offered for coverage levels and costs.
• There is a 60-day deadline to enroll after PEHP coverage ends.

• Typically, it is requested or advised that you continue to cover your child on your plan. Please refer to mission guidelines for details.
• Use the Out-of-State network to find in-network providers and avoid balance billing.

• You must notify PEHP if coverage is acquired because of marriage.
• Call 801-366-7755 if your dependent isn't sure if they should be added to a spouse's plan.
• If your dependent will be covered by their spouse's plan, see detailed Coordination of Benefits information.
• Birth-related healthcare expenses are covered for your child but not grandchild.

• PEHP coverage is still available.
• You must notify PEHP within 60 days if other coverage is acquired because of employment.
• Call 801-366-7755 if your dependent isn't sure if they should sign up for their employer's coverage.
• See detailed Coordination of Benefits information.

Important Things to Know

• Coverage for your 26-year-old dependent will end on the last day of the month in which they turn 26.
• Your dependent may have several coverage options:
  • COBRA continuation coverage is available through PEHP. COBRA rights and rates will be mailed when coverage ends.
  • Coverage is available through the Health Insurance Marketplace.
  • Your dependent may be eligible for coverage from their employer or, if married, their spouse's employer.

Time is of the essence. Your dependent has a short window of time after turning 26 to secure coverage. If they fail to do so, they will have to wait until the next open enrollment period to get coverage.

COBRA Continuation Coverage

• Your dependent is eligible for up to 36 months of coverage.
• COBRA costs 102% of the full premium.
• There is a 60-day deadline to enroll after PEHP coverage ends.
• Coverage is continuous from loss of PEHP coverage (no lapse).
• Benefits are identical to previous coverage.
• Deductibles and maximum out-of-pocket limits applied during your current plan year (before moving to COBRA) will carry over until the plan year renews.
• Plan changes are available only at annual enrollment.
• COBRA coverage can be terminated at any time per member request.

Health Insurance Marketplace

• Marketplace coverage may be more cost effective than COBRA.
• Government subsidies are available for those below 400% of poverty.
• You can compare plans that are offered for coverage levels and costs.
• There is a 60-day deadline to enroll after PEHP coverage ends.
• Resources available to members who are interested include:
  • www.HealthCare.gov
  • www.healthcare.gov/get-coverage
• National Marketplace: 800-318-2596 (24/7), English/Spanish/150+ additional languages

If enrolled in COBRA, your dependent can only change to a Marketplace plan during the Marketplace open enrollment period, or if they have another qualifying event such as marriage or birth of a child.

Employer-Sponsored Health Coverage

• Loss of PEHPcoverage is a qualifying event to add other coverage if available through your dependent's employer or their spouse's employer.
• There is typically a 30/60-day deadline to enroll after PEHP coverage ends.

While your plan covers most medical services, PEHP doesn't cover certain procedures that are not medically necessary, experimental, or cosmetic. In addition, some services require preauthorization from PEHP before they will be covered to determine medical necessity. See your Master Policy for a list of limited and excluded services. You can also call us at 801-366-7555 or 800-765-7347.

Common Non-Covered Services

• Services that require preauthorization that were not authorized by PEHP, including genetic testing, diagnostic 3D mammograms or molecular diagnostics. See list of procedures that require preauthorization.
• Court-ordered drug screening or confirmatory drug testing.
• All charges for services received because of an Industrial Claim (on-the job) injury or illness.
• Residential treatment center, which is not providing in-patient services, services for residential treatment, day treatment and/or intensive outpatient treatment. (Most plans don’t cover this. Check your Master Policy).
• Services or medications used for sexual dysfunction or enhancement, including but not limited to: Cialis, Sildenafil, and Viagra.
• Procedures solely for cosmetic purposes such as breast augmentation, rhinoplasty, or obesity surgery, including any complications.
• Charges for scholastic education, vocational training, learning disabilities, or behavior modification.
• Diet or nutritional counseling except in conjunction with diabetes education, anorexia, bulimia, or as allowed under the Affordable Care Act.
• Non-FDA approved medications.

Paying for Non-Covered Services

Use your HSA or Flex plan money to pay for charges. Many non-covered services are considered qualified medical expenses by the IRS, making it possible to use HSA or Flex funds for those services even if PEHP doesn’t pay. See the official list of qualified medical expenses.

• Living out of state. PEHP provides coverage for you and/or your children while living out-of-state. You must provide us with your out-of-state address, so we can make sure claims are paid correctly and you can access your full benefits coverage.

  Make sure you use in-network providers (see Finding an Out-of-State Provider below) whenever possible to get the benefit of PEHP’s contracted rates and avoid balance billing. This includes emergency services.

• Traveling out of state. If you’re traveling outside of Utah for business or vacation, you’re covered for any urgent or emergent care needs in another state. Make sure you use in-network providers (see Finding an Out-of-State Provider below) whenever possible to get the benefit of PEHP’s contracted rates and avoid balance billing. This includes emergency services.

  However, PEHP does not cover non-emergent or elective services out-of-state. In rare circumstances, it may be necessary to receive services outside of Utah because they’re not available in Utah. Please note these services must be authorized and coordinated through PEHP’s clinical staff in advance. Call us at 801-366-7400 or 855-366-7400.

• Finding an out-of-state provider. Log in into your PEHP account and go to our Provider Directory, then out-of-state network.

  Consider consulting a medical professional online 24/7 through E-Care for your urgent care needs.

  By using contracted providers, you ensure you get the best discounts and the lowest cost. Remember, providers are contracted only at the addresses listed in the directory.

  Please note any urgent or emergent service that is provided by an out-of-network provider may leave you subject to balance billing for any amount above PEHP’s contracted rate.

• Traveling or living abroad. PEHP provides coverage while you are traveling or living abroad. PEHP does not have a network for out-of-country providers. Instead, we reimburse out-of-country medical services up to PEHP’s Utah rates, but only if the type of service would normally be covered. If you have questions about coverage outside of Utah or how to find an out-of-state provider, please contact us at 801-366-7555.

You can add or remove a dependent from your PEHP plan anytime during the year when it coincides with a Midyear Event – birth or adoption of a child, marriage, divorce, dependent reaches age 26, retirement, Medicare enrollment, or loss of other coverage. It’s important to notify PEHP immediately when you have a Midyear Event as there is a limited window to make these updates.

Depending on your employer it could be 30, 31, or 60 days from birth, marriage or adoption. Please check with your HR or PEHP to find out which deadline applies to you. If you miss this deadline, you won’t be able to add your dependent until your next annual enrollment period, and PEHP will not pay any claims for your dependent.

To add/remove dependents, log in to your PEHP account and choose “Enroll or Change Coverage” under the “My Benefits” menu. In the enrollment portal, find the MIDYEAR EVENTS section on the bottom left of the page.

Some medical services and prescriptions require preauthorization before you receive treatment. To get preauthorization, your doctor must call PEHP (801-366-7555). Most doctors know how and when to do this, but it's your responsibility to verify. Otherwise, your benefits could be reduced or denied.

Learn More.

Preauthorization is required for:

• Attended Sleep Studies: For ages 18 and older.
• Facility-based Sleep Studies: Conducted in a medical facility.
• Home Sleep Studies: When equipment is obtained from a facility, doctor’s office, or certain hospitals.

No preauthorization needed with equipment from an in-network Durable Medical Equipment (DME) provider.

Where to Receive Services

Use in-network providers to avoid extra costs. Check the PEHP Provider Directory for cost comparisons of sleep equipment providers.

Unattended Sleep Studies

Only two unattended sleep studies are covered per plan year, with one study allowed per testing session, whether at a hospital, office/clinic, or home.