This guide will help you understand basic health insurance terms, how to maximize your PEHP benefits, and give you the tools you need to make the best healthcare decisions for you and your family.
If you need help with your benefits when PEHP offices are closed, you can find valuable information when you log in to your PEHP account, including benefit summaries, claims, forms, lists of participating providers, access your PEHP ID card, and send us information via the Message Center.
Urgent Care » Did you know you can consult a medical professional from anywhere, anytime? With Intermountain Connect Care, you can consult a clinician for non-emergency medical conditions. If you're on the Traditional Plan, it's only $10 per visit. If you're on an HSA plan, the cost is $49 per visit or $10 after you meet your deductible. Connect Care is available on all PEHP networks. Download the Connect Care app. If your condition can’t be addressed remotely, you can find an urgent care center in the PEHP Provider Lookup when you log in to your PEHP account. Just click on the “Find a Facility” tab and pick Urgent Care on the list of Facility Types.
Out of State Coverage (not Medicare Supplement) » PEHP members can access a nationwide network of doctors and hospitals for urgent services while travelling, or for regular medical care while living outside Utah. To find an out-of-state provider, log in into your PEHP account and click on the “Find a Provider and Costs” icon on the top right, then out-of-state network. PEHP has contract agreements with MultiPlan/PHCS and BeechStreet for out-of-state coverage. By using in-network providers, you ensure you get the best discounts, the lowest cost, and avoid balance billing.
Out of Country Coverage (not Medicare Supplement) » PEHP provides coverage for members who experience urgent or emergent medical issues while travelling outside the United States. This is a reimbursement benefit. To qualify for this benefit, you’ll need to submit a copy of the original foreign claim and documentation of the services. PEHP will reimburse eligible medical expenses according to your plan’s benefits. You can find a claim form online when you log in to your PEHP account in the “My Benefits” section, just look for the “Self-Pay Medical Claim” form. Please note this benefit is only available for members who experience incidental medical issues while travelling. It does not cover medical tourism, complications from medical tourism, or medical evacuation back to the United States.
Medicare Supplement Outside Utah » If you’re a PEHP Medicare Supplement Member, you don’t have to see PEHP doctors and hospitals in Utah. Your PEHP plan follows Medicare guidelines and uses Medicare approved doctors and hospitals, even outside the State of Utah. Just show your Medicare and PEHP cards when you go for services, so your doctor knows you have a supplemental plan. Your PEHP Medicare Supplement plan will pay a percentage of your deductible and coinsurance, after Medicare has made their payment. If you still need assistance, log in to your PEHP account to send us a secure message.
Medicare Supplement Outside USA » PEHP provides coverage for Medicare Supplement members who experience urgent or emergent medical issues while travelling outside the United States. This is a reimbursement benefit. To qualify for this benefit, you’ll need to submit a copy of the original foreign claim and documentation of the services. PEHP will reimburse eligible medical expenses at a percentage, according to your plan’s benefits, with a lifetime maximum of $50,000 per person for out-of-country coverage. You can find a claim form online when you log in to your PEHP account in the “My Benefits” section, just look for the “Self-Pay Medical Claim” form. Please note this benefit is only available for members who experience incidental medical issues while travelling. It does not cover medical tourism, complications from medical tourism, or medical evacuation back to the United States.
Trouble filling a prescription (Medicare Supplement) » Are you having trouble filling a prescription? To check if your medication is covered, or if it requires pre-authorization, please call Express Scripts at 1-800-922-1557. You can ask your pharmacist to provide you with a short supply of your covered medication or pay out of pocket and submit your claim for reimbursement at your regular benefit level.
Trouble filling a prescription » If you’re not sure your medication is covered or need to check if it requires pre-authorization, please review the PEHP Covered Drug List. If you’re not able to resolve your prescription issues and need to pick up your medication today, ask your pharmacist to provide you with a short supply of your medication. If you pay out of pocket for your covered medication, you can submit your receipt for reimbursement at your regular pharmacy benefits.
Submitting a pharmacy claim » If you need to submit a self-pay or secondary pharmacy claim to your PEHP plan, please log into your PEHP account and look for the Express Scripts Personal Account link in the “My Benefits” tab. You will be taken to the Express Scripts website where you can print a form to submit for any eligible reimbursement or to submit claims to your PEHP plan as a secondary carrier.
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.
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.
Regularly getting preventive services may help avoid health problems as you age. Remember, many preventive services are covered by PEHP at 100% when done in-network. See a list of preventive benefits.
Some screenings that may be recommended for you:
Find out how to receive your cash back
*This benefit isn't available to Salt Lake County employees. For Salt Lake City employees, the incentive will be paid into an HSA. Incentive is subject to income taxes.
Preauthorization » If you get a colonoscopy, you must get pre-authorization from PEHP for any level of anesthesia higher than “conscious sedation,” which is medically appropriate in most cases. Without preauthorization, you would be responsible to pay for “general anesthesia/ monitored anesthesia care.” Call 801-366-7555 to get pre-authorization.
Preventive » Your colonoscopy is only considered “preventive” if it is done to screen for colorectal cancer. If it is performed because of a known elevated risk of colorectal cancer or as a form of treatment to, for example, remove known polyps, the colonoscopy is not considered “preventive” and the normal benefit based on deductible and coinsurance would apply. When performing a colonoscopy, please note doctors will always remove polyps because it is impossible to know if they are cancerous or not.
There are certain providers that PEHP won’t pay anything even if you have out-of-network benefits.
PEHP constantly reviews how providers perform. We run reports on provider practices and review member comments left online or reported by phone. Through this process we identify providers that we feel may put you at risk for overbilling, performing services that are considered risky or are not clinically proven, or generally provide services that are not covered by PEHP. When we determine a provider should be classified as a “no pay provider” we notify all members who visited the provider in the last 12 months, provide a list of alternate providers, and inform any referring physicians.
The No Pay Provider list is available under the Provider Look Up page.
If you have any questions about this process, please contact PEHP Health Benefits Department at 801-366-7555 or 800-765-7347.
PEHP provides coverage for you and/or your children while living out-of-state. It’s important you 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.
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.
Log in into your PEHP account and go to our Provider Lookup, then out-of-state network. If you’re looking for a provider in any state but Alaska or Nevada, select the MultiPlan/PHCS search option. If you’re searching for a provider in Alaska or Nevada, select BeechStreet.
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.
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 or 800-765-7347.
While your PEHP 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.
Use your HSA or Flex plan money to pay for charges. Many uncovered 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.”