Regence BlueCross BlueShield of Utah is an Independent

Licensee of the Blue Cross and Blue Shield Association

SALT LAKE COMMUNITY COLLEGE

EMPLOYEE HEALTH CARE BENEFITS

Booklet

Group Number: 10003141

July 1, 2025

MEDICAL & DENTAL

Regence BlueCross BlueShield of Utah

2890 East Cottonwood Parkway Salt Lake City, UT 84121

Customer Service regence.com

1 (866) 240-9580 Case Management 1 (866) 543-5765

EAP

Employee Assistance Program

1 (866) 750-1327

Surprise Billing Model Notice: Self-Funded (Eff. 01012023)

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re protected from balance billing for:

Emergency services If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

Surprise Billing Model Notice: Self-Funded (Eff. 01012023)

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.

• Generally, your health plan must:

o Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).

o Cover emergency services by out-of-network providers.

o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

o Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact www.cms.gov/nosurprises/consumers or call the No Surprises Help Desk at 1-800-985-3059.

Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

NONDISCRIMINATION NOTICE

11022024_Regence_ID_OR_UT_NDMA

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Regence does not exclude people or treat them less favorably because of race, color, national origin, age, disability, or sex.

Regence:

Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:

• Qualified sign language interpreters

• Written information in other formats (large print, audio, accessible electronic formats, other formats).

Provides free language assistance services to people whose primary language is not English, which may include:

• Qualified interpreters

• Information written in other languages.

If you need reasonable modifications, appropriate auxiliary aids and services, or language assistance services, contact the Civil Rights Coordinator.

If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance. You can file a grievance in person or by mail, fax, or email.

If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

Customer Service Civil Rights Coordinator PO Box 1106 Lewiston, ID 83501-1106 Phone: 1-888-344-6347, (TTY: 711) Fax: 1-888-309-8784 Email: CS@regence.com

Medicare Customer Service Phone: 1-800-541-8981 (TTY: 711) Email: medicareappeals@regence.com

VSP Customer Service Phone: 1-844-299-3041

TTY: 1-800-428-4833

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:CS@regence.com mailto:medicareappeals@regence.com https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

Language assistance

11022024_Regence_ID_OR_UT_NDMA

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al

1-888-344-6347 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言

援助服務。請致電 1-888-344-6347 (TTY: 711)。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-

344-6347 (TTY: 711).

주의: 한국어를 사용하시는 경우, 언어 지원

서비스를 무료로 이용하실 수 있습니다. 1-888-

344-6347 (TTY: 711) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-344-6347 (TTY:

711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.

Звоните 1-888-344-6347 (телетайп: 711).

ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.

Appelez le 1-888-344-6347 (ATS : 711)

注意事項：日本語を話される場合、無料の言語支

援をご利用いただけます。1-888-344-6347

(TTY:711）まで、お電話にてご連絡ください。

ti’go Diné

Bizaad, saad

1-888-344-6347 (TTY: 711.)

FAKATOKANGA’I: Kapau ‘oku ke Lea-

Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai atu ha tokoni ta’etotongi, pea te ke lava ‘o ma’u ia.

ha’o telefonimai mai ki he fika 1-888-344-6347 (TTY:

711)

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno.

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711)

ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ

គឺអាចមានសំរារ់រំបរ ើអ្នក។ ចូរ ទូរស័ព្ទ 1-888-344-

6347 (TTY: 711)។

ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧ ਿੱ ਚ

ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-888-344-

6347 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ।

ACHTUNG: Wenn Sie Deutsch sprechen, stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfügung. Rufnummer: 1-888-344-6347 (TTY: 711)

ማስታወሻ:- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፤ በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው:- 711)፡፡

УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-344-6347 (телетайп: 711)

ध्यान दिनुहोस्: तपारं्इले नेपाली बोल्नुहुन्छ भने तपारं्इको

दनम्ति भाषा सहायता सेवाहरू दनिः शुल्क रूपमा उपलब्ध छ ।

फोन गनुुहोस् 1-888-344-6347 (दिदिवार्इ: 711

ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit.

Sunați la 1-888-344-6347 (TTY: 711)

MAANDO: To a waawi [Adamawa], e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-344-6347

(TTY: 711)

โปรดทราบ: ถา้คณุพูดภาษาไทย คณุสามารถใชบ้รกิารชว่ยเหลอืทางภาษาไดฟ้ร ี โทร 1-888-

344-6347 (TTY: 711)

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-888-344-6347 (TTY:

711)

Afaan dubbattan Oroomiffaa tiif, tajaajila gargaarsa afaanii tola ni jira. 1-888-344-6347 (TTY: 711) tiin bilbilaa.

شما ی برا گانیرا بصورتی زبان لاتیتسه د،یکن ی مصحبت فارسی زبان به اگر: توجه

.د یریبگ تماس (TTY: 711) 6347-344-888-1 با. باشد ی م فراهم

6347-344-888-1ملحوظة: إذا كنت تتحدث فاذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم

TTY: 711)هاتف الصم والبكم )رقم

UUIHSBLPBK / UUIHSHSA3BK / UU0125IHSEPBK

Salt Lake Community College, 10003141, Effective July 1, 2025

Salt Lake Community College Medical Plan: BluePoint

In-Network Provider What You Pay Out-of-Network Provider

What You Pay

Deductible per Plan Year $600 Individual / $1,200 Family $2,000 Individual / $4,000 Family

Out-of-Pocket Maximum per Plan Year $3,500 Individual / $7,000 Family $5,000 Individual / $10,000 Family

Medical Services

Ambulance Services 20% after deductible 20% after deductible

Ambulatory Surgical Center 20% after deductible 40% after deductible

Emergency Room (Including Professional Charges) 20% after deductible 20% after deductible

Hearing Aids

• Limit: $2,500 per Claimant per Plan Year 20% after deductible 40% after deductible

Hearing Exam

• Limit: 1 routine exam per Claimant per Plan Year

$25 copay per visit

(deductible waived) 40% after deductible

Home Health Care $25 copay per visit (deductible waived)

40% after deductible

Home Infusion Therapy

• Limit: $50,000 per Claimant per Plan Year for Parenteral Nutrition

$25 copay per visit (deductible waived) 40% after deductible

Hospice Care 20%

(deductible waived) 40% after deductible

Hospital Care 20% after deductible 40% after deductible

Infertility (Diagnosis & Treatment)

• Limit: $5,000 per Claimant Lifetime $25 copay per visit (deductible waived)

40% after deductible

Maternity Care 20% after deductible 40% after deductible

Mental Health/Substance Use Disorder Therapy Services

- Inpatient

20% after deductible 40% after deductible

Mental Health/Substance Use Disorder Therapy Services

- Outpatient

$25 copay per visit (deductible waived)

40% after deductible

Mental Health/Substance Use Disorder Non-Therapy Services

- Outpatient

20% after deductible 40% after deductible

Neurodevelopmental Therapy

• Limit: 30 visits per Claimant per Plan Year combined with Outpatient Rehabilitation

$25 copay per visit (deductible waived)

40% after deductible

Nutritional Counseling

• Limit: Diabetic nutritional counseling only 20% after deductible 40% after deductible

Office Visits Primary - $25 copay per visit (deductible waived) /

Specialist - $35 copay per visit (deductible waived)

40% after deductible

Orthotics – Foot

• Limit: $200 per Claimant per Plan Year 20% after deductible 40% after deductible

Preventive Care/Immunizations

• Preventive services and immunizations are covered according to guidelines set forth by the United States Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration

(HRSA)

0% coinsurance

(deductible waived) 40% after deductible

In-Network Provider What You Pay

Out-of-Network Provider What You Pay

Radiology and Laboratory – Outpatient Minor 20% after deductible 40% after deductible

Radiology and Laboratory – Outpatient Major $50 copay per visit after deductible

$50 copay per visit + 40% after deductible

Rehabilitation Services - Inpatient

• Limit: 60 days per Claimant per Plan Year 20% after deductible 40% after deductible

Rehabilitation Services – Outpatient

• Limit: 30 visits per Claimant per Plan Year combined with Outpatient Neurodevelopmental Therapy

$25 copay per visit (deductible waived) 40% after deductible

Repair of Teeth due to Injury

• Limit: $1,000 per Claimant per Plan Year 20% after deductible 40% after deductible

Skilled Nursing Facility (SNF) Care

• Limit: 60 days per Claimant per Plan Year 20% after deductible 40% after deductible

Spinal Manipulations

• Limit: 20 visits per Claimant per Plan Year $25 copay per visit (deductible waived)

40% after deductible

Telehealth $10 copay per visit (deductible waived) 40% after deductible

Temporomandibular Joint (TMJ) Disorders

• Limit: $500 per Claimant Lifetime 20% after deductible 40% after deductible

Urgent Care $35 copay per visit

40% after deductible

Salt Lake Community College Medical Plan: HSA Healthplan 3.0

In-Network Provider What You Pay

Out-of-Network Provider What You Pay

Deductible per Plan Year $1,700 Individual / $3,400 Family $3,400 Individual / $7,000 Family

Out-of-Pocket Maximum per Plan Year $3,500 Individual / $7,000 Family $7,000 Individual / $14,000 Family

Medical Services

Ambulance Services 10% after deductible 10% after deductible

Ambulatory Surgical Center 10% after deductible 30% after deductible

Emergency Room (Including Professional Charges)

10% after deductible 10% after deductible

Hearing Aids

• Limit: $2,500 per Claimant per Plan Year

10% after deductible 30% after deductible

Hearing Exams

• Limit: 1 routine exam per Claimant per Plan

Year

10% after deductible 30% after deductible

Home Health Care 10% after deductible 30% after deductible

Home Infusion Therapy

• Limit: $50,000 per Claimant per Plan Year for Parenteral Nutrition

$25 copay per visit after deductible 30% after deductible

Hospice Care 10% after deductible 30% after deductible

Hospital Care 10% after deductible 30% after deductible

Infertility (Diagnosis & Treatment)

• Limit: $5,000 per Claimant Lifetime

10% after deductible 30% after deductible

Maternity Care 10% after deductible 30% after deductible

Mental Health/Substance Use Disorder Therapy Services

- Inpatient

10% after deductible 30% after deductible

Mental Health/Substance Use Disorder Therapy Services

- Outpatient

$25 copay per visit after deductible 30% after deductible

Mental Health/Substance Use Disorder Non- Therapy Services

- Outpatient 10% after deductible 30% after deductible

Neurodevelopmental Therapy

• Limit: 30 visits per Claimant per Plan Year combined with Outpatient Rehabilitation

10% after deductible 30% after deductible

Nutritional Counseling

• Limit: Diabetic nutritional counseling only

10% after deductible 30% after deductible

Office Visits Primary - $25 copay per visit after deductible

Specialist- $35 copay per visit after deductible

30% after deductible

Orthotics – Foot

• Limit: $200 per Claimant per Plan Year 10% after deductible 30% after deductible

Preventive Care/Immunizations

• Preventive services and immunizations are covered according to guidelines set forth by the United States Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration

(HRSA).

0%

30% after deductible

Radiology and Laboratory – Outpatient (Minor and Major)

10% after deductible 30% after deductible

In-Network Provider What You Pay

Out-of-Network Provider What You Pay

Rehabilitation Services

• Limit: 60 Inpatient days per Claimant per Plan

Year

• Limit: 30 Outpatient visits per Claimant per Plan Year combined with Outpatient Neurodevelopmental Therapy

10% after deductible 30% after deductible

Repair of Teeth due to Injury

• Limit: $1,000 per Claimant per Plan Year

10% after deductible 30% after deductible

Skilled Nursing Facility (SNF) Care

• Limit: 60 days per Claimant per Plan Year

10% after deductible 30% after deductible

Spinal Manipulations

• Limit: 20 spinal manipulations per Claimant per Plan Year 10% after deductible 30% after deductible

Telehealth $10 copay per visit after deductible 30% after deductible

Temporomandibular Joint (TMJ) Disorders

• Limit: $500 per Claimant Lifetime 10% after deductible 30% after deductible

Urgent Care $35 copay per visit after deductible 30% after deductible

Salt Lake Community College Expressions Active Dental Plan

In-Network Dentist What You Pay

Out-of-Network Dentist What You Pay

Deductible per Plan Year $0

Benefit Maximum per Plan Year $1,500

Preventive Dental Services

Cleaning and Examinations

• 2 cleanings per plan year with a 3rd being covered with qualifying diagnosis

• 2 preventive oral examinations per plan year

0% coinsurance 0% coinsurance + balance billing

X-rays

• 1 complete intra-oral mouth and 1 panoramic mouth x-ray once in a 3-year period

0% coinsurance 0% coinsurance + balance billing

Other Preventive Dental Services

• Claimants under age 18 for sealants (permanent bicuspids and molars only)

• Claimants under age 12 for space maintainers

• Claimants under age 18 and limited to 2 treatments per plan year for topical fluoride application

• Silver Diamine Fluoride – 2 per tooth per plan year

0% coinsurance 0% coinsurance + balance billing

Basic and Restorative Dental Services

Periodontal Services

• 4 periodontal maintenance per plan year

• 1 per quadrant per plan year for periodontal scaling and root planing

20% coinsurance 20% coinsurance + balance billing

Endodontic Services (Fillings, Extractions) 20% coinsurance 20% coinsurance + balance billing

Emergency and Other Basic Dental Services 20% coinsurance 20% coinsurance + balance billing

Major Dental Services

Bridges

• Replacement bridges once per 5 years after placement

50% coinsurance 50% coinsurance + balance billing

Crowns, Inlays, and Onlays

• Replacement crowns, inlays or onlays once per tooth, 5 years after placement

50% coinsurance 50% coinsurance + balance billing

Dentures (Full and Partial)

• Replacement dentures 5 years after placement

50% coinsurance 50% coinsurance + balance billing

Implants 50% coinsurance 50% coinsurance + balance billing

Orthodontia

Orthodontia Services

• $750 per Claimant per plan year

• $1,500 per Claimant lifetime

• No waiting period for orthodontic services

50% coinsurance 50% coinsurance + balance billing

Introduction

Salt Lake Community College (hereafter referred to as the "Plan Sponsor") has restated the Salt Lake Community College Employee Health Care Benefits (hereafter referred to as the "Plan") effective July 1, 2025. This Booklet provides the written description of the terms and benefits of coverage available under the Plan. This Booklet replaces any plan description, Booklet or certificate previously issued by the Plan Sponsor and makes it void.

The Booklet is not meant to interpret, extend, or change the provisions of the Plan in any way. Benefits under this Plan will be paid only if the Plan Sponsor decides, in their sole discretion, that you are entitled to them. The provisions of the Plan may only be determined fully and completely from the actual Plan document, which is available from the Plan Sponsor. Prior to amendments, the Plan Document is this Booklet. If the Plan Document and this Booklet differ, the Plan Document will prevail. No oral interpretations can change this Plan.

The Booklet includes separate sections for Medical Benefits, Prescription Medications benefits, and Dental Benefits, all of which are separate and independent plans. Each section contains the complete benefits, conditions, limitations, and important information that can only be found within that particular section, such as the percentages paid, Deductibles, Copayments, and Out-of-Pocket Maximum amounts under each Plan.

The Plan Sponsor intends the Plan to be permanent, but since future conditions affecting the Plan Sponsor cannot be anticipated or foreseen, the Plan Sponsor reserves the right to amend, modify or terminate the Plan, or any portion thereof, in any manner, at any time, regardless of Your, Your Spouse's (or Domestic Partner's) and/or Your Child's health or treatment status, which may result in the termination or modification of Your coverage and/or the coverage for Your Spouse (or Domestic Partner) and/or Children. If the Plan is amended, modified, or terminated, the rights of You, Your Spouse (or Domestic Partner) and/or Your Children are limited to services and Allowed Amounts incurred prior to the Plan's amendment, modification or termination, which will be paid as provided under the terms of the Plan as it existed at the time they were incurred.

All benefits under the Plan are self-insured by the Plan Sponsor. Participants and the Plan Sponsor share the cost of providing benefits. The cost of providing benefits are charged first to Participants' contributions and then paid out of the general assets of the Plan Sponsor. The Plan Sponsor shall from time to time determine the amount of contributions payable by Participants.

The Plan Sponsor is the Plan Administrator. The Plan sponsor has entered into an agreement with Regence BlueCross BlueShield of Utah (hereafter referred to as the "Claims Administrator"), as a third-party administrator, to assist the Plan Sponsor in the Plan's claims administration and certain other administrative matters. The Claims Administrator provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims, except in the case of claims that exceed certain amounts which may be reinsured.

CONTACT INFORMATION

Customer Service: 1 (866) 240-9580

(TTY: 711)

Phone lines are open Monday – Friday 5 a.m. – 8 p.m. and Saturday 8 a.m. – 4:30 p.m. Pacific Time.

Contact Customer Service:

• if You have questions;

• if You would like to learn more about Your coverage;

• if You would like to request written or electronic information regarding any other plan that the Claims Administrator offers;

• to talk with one of the Claims Administrator's Customer Service representatives;

• via the Claims Administrator's website, regence.com, to submit a claim online or chat live with a Customer Service representative;

• to request a copy of Your identification card (or print a copy via the Claims Administrator's website);

or

• for assistance in a language other than English.

Case Management: Case managers assess Your needs, develop plans, coordinate resources and negotiate with Providers. For additional information refer to the Medical Benefits Section or call Case Management at 1 (866) 543-5765.

BlueCard® Program: This unique program enables You to access Hospitals and Physicians when traveling outside the four-state area Regence BlueCross BlueShield of Utah serves (Idaho, Oregon, Utah and Washington), as well as receive care in 200 countries around the world. Call Customer Service to learn how to have access to care through the BlueCard Program.

Using Your Booklet

ACCESSING MEDICAL PROVIDERS

You are not restricted in Your choice of Provider for care or treatment of an Illness or Injury. You control Your out-of-pocket expenses by choosing between "In-Network" and "Out-of-Network" Providers.

• In-Network. Choosing In-Network Providers saves You the most in Your out-of-pocket expenses.

In-Network Providers will not bill You for balances beyond any Deductible, Copayment and/or Coinsurance for Covered Services.

• Out-of-Network. Choosing Out-of-Network Providers means Your out-of-pocket expenses will be higher than choosing an In-Network Provider. Also, an Out-of-Network Provider may bill You for balances beyond any Deductible, Copayment and/or Coinsurance. This is referred to as balance billing. Refer to the "Notice: Your Rights and Protections Against Surprise Medical Bills" attached to this Booklet for information regarding reimbursement and balance billing applicable to Out-of-Network Providers for certain services.

ACCESSING DENTAL PROVIDERS

You are not restricted in Your choice of Dentist for dental care or treatment. You control Your out-of-pocket expenses by choosing between "In-Network Dentist" and "Out-of-Network Dentist."

• In-Network Dentist. Choosing In-Network Dentists saves You the most in Your out-of-pocket expenses. In-Network Dentists will not bill You for balances beyond any Deductible and/or Coinsurance for Covered Services.

• Out-of-Network Dentist. Choosing Out-of-Network Dentists means Your out-of-pocket expenses will be higher than choosing an In-Network Dentist. Also, an Out-of-Network Dentist may bill You for balances beyond any Deductible and/or Coinsurance. This is referred to as balance billing.

For each benefit, the Provider or Dentist You may choose and Your payment amount for each Provider option is indicated. See the Definitions Section for a complete description of In-Network Providers and Out-of-Network Providers and an In-Network Dentist and Out-of-Network Dentist. You can go to regence.com for further Provider network information.

ADDITIONAL ADVANTAGES OF PARTICIPATION

The Claims Administrator provides access to discounts on select items and services, personalized health/dental care planning information, health/dental-related events and innovative health/dental decision tools, as well as a team dedicated to Your personal health/dental care needs. You also have access to the Claims Administrator's website and mobile application to help You navigate Your way through health/dental care decisions. For access, You just set up Your free account once and it is always up to You whether to participate. THESE SERVICES ARE VOLUNTARY, NOT INSURANCE AND ARE OFFERED IN ADDITION TO THE BENEFITS IN YOUR BOOKLET. Additional information about some programs and services can be found in the Value-Added Services Appendix at the end of the Booklet.

• Go to regence.com or the Claims Administrator's mobile application. You can use the Claims Administrator's secure applications to:

view recent claims, benefits and coverage;

find a contracting Provider or dental Provider;

use tools to estimate upcoming health care costs and otherwise help You manage health care expenses;

get suggestions to improve or maintain wellness and participate in self-guided motivational online wellness programs; and access information about Regence Advantages. Regence Advantages is a discount program that gives You access to savings on a variety of health-related products and services. The Claims Administrator has contracted with several program partners, listed on the secure applications, to offer discounts on their products and services, such as hearing care, health and wellness products and vision care.*

*NOTE: If You choose to access these discounts, You may receive savings on an item or service that is covered by this Plan, that also may create savings or administrative fees for the Claims Administrator.

ANY SUCH DISCOUNTS OR COUPONS ARE COMPLEMENTS TO THE PLAN, BUT ARE NOT

INSURANCE.

Table of Contents

NOTICES

WOMEN'S HEALTH AND CANCER RIGHTS ACT

THE NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT

NOTICE OF PRIVACY PRACTICES UNDER HEALTH INSURANCE PORTABILITY AND

ACCOUNTABILITY ACT (HIPAA)

UNDERSTANDING YOUR BENEFITS

ALLOWED AMOUNT:

COINSURANCE (PERCENTAGE YOU PAY)

COPAYMENTS

DEDUCTIBLES – BLUEPOINT

DEDUCTIBLES – HIGH DEDUCTIBLE HEALTH PLAN

HOW PLAN YEAR BENEFITS RENEW

MAXIMUM BENEFITS

OUT-OF-POCKET MAXIMUM – BLUEPOINT

OUT-OF-POCKET MAXIMUM – HIGH DEDUCTIBLE HEALTH PLAN

MEDICAL BENEFITS – BLUEPOINT

CASE MANAGEMENT

PREAUTHORIZATION

PREVENTIVE VERSUS DIAGNOSTIC SERVICES

PLAN YEAR DEDUCTIBLES

PLAN YEAR OUT-OF-POCKET MAXIMUM

PREVENTIVE CARE AND IMMUNIZATIONS

OFFICE OR URGENT CARE VISITS – ILLNESS OR INJURY

OTHER PROFESSIONAL SERVICES

AMBULANCE SERVICES

APPROVED CLINICAL TRIALS

AUTISM SPECTRUM DISORDER SERVICES

BLOOD BANK

DENTAL HOSPITALIZATION

DETOXIFICATION

DIABETIC EDUCATION

DIABETIC NUTRITIONAL THERAPY

DIALYSIS

DURABLE MEDICAL EQUIPMENT

EMERGENCY ROOM (INCLUDING PROFESSIONAL CHARGES)

GENE THERAPY AND ADOPTIVE CELLULAR THERAPY

HEARING AIDS AND EVALUATIONS

HOME HEALTH CARE

HOSPICE CARE

HOSPITAL CARE – INPATIENT, OUTPATIENT AND AMBULATORY SURGICAL CENTER

INFERTILITY TREATMENT

INFUSION THERAPY

MAJOR DIAGNOSTIC TESTING

MATERNITY CARE/ADOPTION BENEFIT

MEDICAL FOODS

MENTAL HEALTH OR SUBSTANCE USE DISORDER SERVICES

NEURODEVELOPMENTAL THERAPY

NEWBORN CARE

ORTHOTIC DEVICES

PROSTHETIC DEVICES

RADIOLOGY AND LABORATORY SERVICES

REHABILITATION SERVICES

REPAIR OF TEETH

ROUTINE HEARING EXAMINATIONS

SKILLED NURSING FACILITY

SPINAL MANIPULATIONS

TEMPOROMANDIBULAR JOINT (TMJ) DISORDERS

TRANSPLANTS

VIRTUAL CARE

MEDICAL BENEFITS – HIGH DEDUCTIBLE HEALTH PLAN

CASE MANAGEMENT

PREAUTHORIZATION

PREVENTIVE VERSUS DIAGNOSTIC SERVICES

PLAN YEAR DEDUCTIBLES

PLAN YEAR OUT-OF-POCKET MAXIMUM

PREVENTIVE CARE AND IMMUNIZATIONS

OFFICE OR URGENT CARE VISITS – ILLNESS OR INJURY

OTHER PROFESSIONAL SERVICES

AMBULANCE SERVICES

APPROVED CLINICAL TRIALS

AUTISM SPECTRUM DISORDER SERVICES

BLOOD BANK

DENTAL HOSPITALIZATION

DETOXIFICATION

DIABETIC EDUCATION

DIABETIC NUTRITIONAL THERAPY

DIALYSIS

DURABLE MEDICAL EQUIPMENT

EMERGENCY ROOM (INCLUDING PROFESSIONAL CHARGES)

GENE THERAPY AND ADOPTIVE CELLULAR THERAPY

HEARING AIDS AND EVALUATIONS

HOME HEALTH CARE

HOSPICE CARE

HOSPITAL CARE – INPATIENT, OUTPATIENT AND AMBULATORY SURGICAL CENTER

INFERTILITY TREATMENT

INFUSION THERAPY

MAJOR DIAGNOSTIC TESTING

MATERNITY CARE/ADOPTION BENEFIT

MEDICAL FOODS

MENTAL HEALTH OR SUBSTANCE USE DISORDER SERVICES

NEURODEVELOPMENTAL THERAPY

NEWBORN CARE

ORTHOTIC DEVICES

PREVENTIVE CARE FOR SPECIFIED CHRONIC CONDITIONS

PROSTHETIC DEVICES

REHABILITATION SERVICES

REPAIR OF TEETH

ROUTINE HEARING EXAMINATIONS

SKILLED NURSING FACILITY

SPINAL MANIPULATIONS

TEMPOROMANDIBULAR JOINT (TMJ) DISORDERS

TRANSPLANTS

VIRTUAL CARE

VALUE-ADDED MEDICAL BENEFITS

JOINT, SPINE, AND MUSCLE PROGRAM

GENERAL PLAN EXCLUSIONS

GENERAL MEDICAL EXCLUSIONS

EXCLUSION PERIOD FOR PREEXISTING CONDITIONS

EXCLUSION EXAMPLES

SPECIFIC EXCLUSIONS

DENTAL BENEFITS

PLAN YEAR DEDUCTIBLES

MAXIMUM BENEFITS

PREVENTIVE AND DIAGNOSTIC DENTAL SERVICES

BASIC AND RESTORATIVE DENTAL SERVICES

MAJOR DENTAL SERVICES

ORTHODONTIC DENTAL SERVICES

GENERAL DENTAL EXCLUSIONS

SPECIFIC EXCLUSIONS

CLAIMS ADMINISTRATION

SUBMISSION OF CLAIMS AND REIMBURSEMENT

CONTINUITY OF CARE

OUT-OF-AREA SERVICES

BLUE CROSS BLUE SHIELD GLOBAL® CORE

CLAIMS RECOVERY

SUBROGATION AND RIGHT OF RECOVERY

COORDINATION OF BENEFITS

INTERNAL COORDINATION OF BENEFITS (ICOB)

APPEAL PROCESS

INTERNAL APPEAL – FIRST LEVEL

INTERNAL APPEAL – SECOND LEVEL

INTERNAL EXPEDITED APPEAL

FILING AN INTERNAL APPEAL

INTERNAL APPEAL DETERMINATION TIMING

VOLUNTARY EXTERNAL APPEAL – INDEPENDENT REVIEW ORGANIZATION (IRO)

VOLUNTARY EXTERNAL EXPEDITED APPEAL – IRO

FILING AN EXTERNAL APPEAL

EXTERNAL APPEAL DETERMINATION TIMING

DEFINITIONS

ELIGIBILITY AND ENROLLMENT

INITIALLY ELIGIBLE, WHEN COVERAGE BEGINS

NEWLY ELIGIBLE CHILDREN

SPECIAL ENROLLMENT

CHANGE IN STATUS

ANNUAL OPEN ENROLLMENT PERIOD

REINSTATEMENT OF COVERAGE

DEFINITIONS

WHEN COVERAGE ENDS

AGREEMENT TERMINATION

WHAT HAPPENS WHEN YOU ARE NO LONGER ELIGIBLE

TERMINATION BY YOU

WHAT HAPPENS WHEN YOUR SPOUSE (OR DOMESTIC PARTNER) OR CHILD IS NO LONGER

ELIGIBLE

OTHER CAUSES OF TERMINATION

FAMILY AND MEDICAL LEAVE

MILITARY LEAVE OF ABSENCE

LEAVE OF ABSENCE

LONG-TERM DISABILITY

COBRA CONTINUATION OF COVERAGE

QUALIFYING EVENTS

NOTIFICATION RESPONSIBILITIES

ELECTING COBRA CONTINUATION COVERAGE

COBRA CONTINUATION PREMIUM PAYMENT

WHEN COBRA CONTINUATION COVERAGE ENDS

GENERAL PROVISIONS AND LEGAL NOTICES

CHOICE OF FORUM

GOVERNING LAW

LIMITATIONS ON LIABILITY

NO WAIVER

NONASSIGNMENT

NOTICES

PLAN SPONSOR IS THE FIDUCIARY

RELATIONSHIP TO BLUE CROSS AND BLUE SHIELD ASSOCIATION

REPRESENTATIONS ARE NOT WARRANTIES

RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION AND HEALTH RECORDS

TAX TREATMENT

CLAIMS ADMINISTRATOR IS NOT RESPONSIBLE FOR HSA FINANCIAL OR TAX

ARRANGEMENTS

WHEN BENEFITS ARE AVAILABLE

DEFINITIONS

APPENDIX: VALUE-ADDED SERVICES

CARE MANAGEMENT

DIABETES MANAGEMENT

EMPLOYEE ASSISTANCE PROGRAM (EAP)

JOINT, SPINE, AND MUSCLE PROGRAM

PREGNANCY PROGRAM

REGENCE EMPOWER

PRESCRIPTION MEDICATIONS – BLUEPOINT (TRADITIONAL)

PRESCRIPTION MEDICATIONS – ICOB

PRESCRIPTION MEDICATIONS – HIGH-DEDUCTIBLE HEALTH PLAN

Salt Lake Community College, 10003141, Effective July 1, 2025

Notices

WOMEN'S HEALTH AND CANCER RIGHTS ACT

Under the Women's Health and Cancer Rights Act, certain breast reconstruction services in connection with a covered mastectomy are protected. If You are receiving benefits in connection with a mastectomy and You, in consultation with Your attending Physician, elect breast reconstruction, coverage under the Plan will be provided (subject to the same provisions as any other benefit) for:

• reconstruction of the breast on which the mastectomy was performed;

• surgery and reconstruction of the other breast to produce a symmetrical appearance; and

• prosthesis and treatment of physical complications of all stages of mastectomy, including lymphedemas.

THE NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT

Under federal law, group health plans offering group health insurance coverage generally may not restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section.

However, the Plan may pay for a shorter stay if the attending Provider (for example, Your Physician, nurse midwife, or Physician assistant), after consultation with the mother, discharges the mother or newborn earlier.

Also, under federal law, plans may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.

In addition, a plan may not, under federal law, require that a Physician or other health care provider obtain preauthorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain Providers or facilities, or to reduce Your out-of-pocket costs, You may be required to obtain preauthorization. For information on preauthorization, contact the Claims Administrator.

NOTICE OF PRIVACY PRACTICES UNDER HEALTH INSURANCE PORTABILITY AND

ACCOUNTABILITY ACT (HIPAA)

This is a general Notice of Privacy Practices under HIPAA. You also will receive a Notice of Privacy Practices from the Claims Administrator who pays claims under this Plan. The specific Privacy Notice(s) You receive from the Claims Administrator will take precedence over this general Notice, if there is any conflict between the two Notices.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), you have certain rights with respect to your Protected Health Information ("PHI"), including the right to know how your PHI may be used by a group health Plan.

This Notice of Privacy Practices ("Notice") covers the following group health Plans (collectively referred to as the "Plan"):

• Medical

• Prescription

• Dental

• EAP

The Plan is required by law to maintain the privacy of your PHI and to provide this Notice to you pursuant to HIPAA. This Notice describes how your PHI may be used or disclosed to carry out treatment, payment, health care operations, or for any other purposes that are permitted or required by law. This Notice also provides you with the following important information:

Salt Lake Community College, 10003141, Effective July 1, 2025

• Your privacy rights with respect to your PHI;

• The Plan's duties with respect to your PHI;

• Your right to file a complaint with the Plan's Privacy Officer and/or to the Secretary of the Office of Civil Rights of the U.S. Department of Health and Human Services; and

• The person or office to contact for further information about the Plan's privacy practices.

PHI is health information (including genetic information) in any form (oral, written, electronic) that:

• Is created or received by or on behalf of the Plan;

• Relates to your past, present or future physical or mental condition, or the provision of health care services to you, or the payment for those health care services; and

• Identifies you or from which there is a reasonable basis to believe the information can be used to identify you.

Health information your employer receives during the course of performing non-Plan functions is not PHI.

For example, health information you submit to your employer to document a leave of absence under the Family and Medical Leave Act is not PHI.

SECTION 1. USES AND DISCLOSURES OF YOUR PHI

Under HIPAA, the Plan may use or disclose your PHI under certain circumstances without your consent, authorization or opportunity to agree or object. Such uses and disclosures fall within the categories described below. Note that not every permissible use or disclosure in a category is listed; however, all the ways in which the Plan is permitted to use or disclose PHI will fall within one of the categories.

General Uses and Disclosures Treatment. The Plan may use and/or disclose your PHI to help you obtain treatment and/or services from Providers. Treatment includes the provision, coordination or management of health care and related services. It also includes, but is not limited to, consultations and referrals between one or more of your Providers. For example, the Plan may disclose to a treating orthodontist the name of your treating dentist so that the orthodontist may ask for your dental x-rays from the treating dentist. The Plan may also disclose information about your prior prescriptions to a pharmacist to determine if any medicines contraindicate a pending prescription.

Payment. The Plan may use and/or disclose your PHI in order to determine your eligibility for benefits, to facilitate payment of your health claims and to determine benefit responsibility. Payment includes, but is not limited to billing, claims management, subrogation, plan reimbursement, reviews for medical necessity and appropriateness of care and utilization review and preauthorizations. For example, the Plan may tell a doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan. The Plan may also disclose your PHI to another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate payment of benefits.

Health Care Operations. The Plan may use and/or disclose your PHI for other Plan operations. These uses and disclosures are necessary to run the Plan and include, but are not limited to, conducting quality assessment and improvement activities, reviewing competence or qualifications of health care professionals, underwriting, premium and other activities relating to Plan coverage. It also includes cost management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general Plan administrative activities. For example, the Plan may use your PHI in connection with submitting claims for stop-loss coverage. The Plan may also use your PHI to refer you to a disease management program, project future costs or audit the accuracy of its claims processing functions.

However, the Plan is prohibited from using or disclosing PHI that is an individual's genetic information for underwriting purposes.

Business Associates. The Plan may contract with individuals or entities known as Business Associates to perform various functions on the Plan's behalf or to provide certain types of services. In order to perform these functions or to provide such services, the Business Associates will receive, create, maintain, use and/or disclose your PHI. For example, the Plan may disclose your PHI to a Business Associate to administer claims or provide pharmacy benefit management services. However, Business Associates will

Salt Lake Community College, 10003141, Effective July 1, 2025 receive, create, maintain, use and/or disclose your PHI on behalf of the Plan only after they have entered into a Business Associate agreement with the Plan and agree in writing to protect your PHI against inappropriate use or disclosure and to require that their subcontractors and agents do the same.

Plan Sponsor. For purposes of administering the Plan, the Plan may disclose your PHI to certain employees of Salt Lake Community College. However, these employees will only use or disclose such information as necessary to perform administration functions for the Plan or as otherwise required by HIPAA, unless you have authorized further disclosures. Your PHI cannot be used for employment purposes without your specific authorization.

Required By Law. The Plan may disclose your PHI when required to do so by federal, state or local law.

For example, the Plan may disclose your PHI when required by public health disclosure laws.

Health or Safety. The Plan may disclose and/or use your PHI when necessary to prevent a serious threat to your health or safety or the health or safety of another individual or the public. Under these circumstances, any disclosure will be made only to the person or entity able to help prevent the threat.

Special Situations In addition to the above, the following categories describe other possible ways that the Plan may use and disclose your PHI without your consent, authorization or opportunity to agree or object. Note that not every permissible use or disclosure in a category is listed; however, all the ways in which the Plan is permitted to use or disclose PHI will fall within one of the categories.

Public Health Activities. The Plan may disclose your PHI when permitted for purposes of public health actions, including when necessary to report child abuse or neglect or domestic violence, to report reactions to drugs or problems with products or devices, and to notify individuals about a product recall.

Your PHI may also be used or disclosed if you have been exposed to a communicable disease or are at risk of spreading a disease or condition.

Health Oversight. The Plan may disclose your PHI to a public health oversight agency for oversight activities authorized by law. Oversight activities can include civil, administrative or criminal actions, audits and inspections, licensure or disciplinary actions (for example, to investigate complaints against Providers); other activities necessary for appropriate oversight of government benefit programs (for example, to investigate Medicare or Medicaid fraud); compliance with civil rights laws and the health care system in general.

Lawsuits, Judicial and Administrative Proceedings. If you are involved in a lawsuit or similar proceeding, the Plan may disclose your PHI in response to a court or administrative order. The Plan may also disclose your PHI in response to a subpoena, discovery request or other lawful process by another individual involved in the dispute, provided certain conditions are met. One of these conditions is that satisfactory assurances must be given to the Plan that the requesting party has made a good faith attempt to provide written notice to you, and the notice provided sufficient information about the proceeding to permit you to raise an objection and no objections were raised or were resolved in favor of disclosure by the court or tribunal.

Law Enforcement. The Plan may disclose your PHI when required for law enforcement purposes, including for the purposes of identifying or locating a suspect, fugitive, material witness or missing person.

Coroners, Medical Examiners and Funeral Directors. The Plan may disclose your PHI when required to be given to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as authorized by law. Also, disclosure is permitted to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent.

Workers' Compensation. The Plan may release your PHI for workers' compensation or similar programs that provide benefits for work-related injuries or illness.

National Security and Intelligence. The Plan may release PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Salt Lake Community College, 10003141, Effective July 1, 2025

Military and Veterans. If you are a member of the armed forces, the Plan may disclose your PHI as required by military command authorities. The Plan may also release PHI about foreign military personnel to the appropriate foreign military authority.

Organ and Tissue Donations. If you are an organ donor, the Plan may disclose your PHI to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Research. The Plan may disclose your PHI for research when the individual identifiers have been removed or when the institutional review board or privacy board has reviewed the research proposal and established protocols to ensure the privacy of the requested information, and approves the research.

Required Disclosure to Secretary The Plan is required to disclose your PHI to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining the Plan's compliance with HIPAA.

Disclosures to Family Members and Personal Representatives The Plan may disclose your PHI to family members, other relatives and your close personal friends but only to the extent that it is directly relevant to such individual's involvement with a coverage, eligibility or payment matter relating to your care, unless you have requested and the Plan has agreed not to disclose your PHI to such individual. The Plan will disclose your PHI to an individual authorized by you, or to an individual designated as your personal representative, provided the Plan has received the appropriate authorization and/or supporting documents. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms:

• A power of attorney for health care purposes, notarized by a notary public;

• A court order of appointment of the person as the conservator or guardian of the individual; or

• An individual who is the parent of a minor child.

However, the Plan will not disclose information to an individual, including your personal representative, if it has a reasonable belief that:

• You have been, or may be, subjected to domestic violence, abuse or neglect by such person or treating such person as your personal representative could endanger you; and

• In the exercise of professional judgment, it is not in your best interest to disclose the PHI.

• This also applies to personal representatives of minors.

Authorization Any uses or disclosures of your PHI not described above will be made only with your written authorization. Most disclosures involving psychotherapy notes will require your written authorization. In addition, the Plan generally cannot use your PHI for marketing purposes or engage in the sale of your PHI without your written authorization. You may revoke your written authorization at any time, so long as the revocation is in writing. Once the Plan receives your authorization, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation.

SECTION 2. RIGHTS OF INDIVIDUALS

You have the following rights with respect to your PHI:

Right to Request Restrictions on PHI Uses and Disclosures. You may request in writing that the Plan restrict or limit its uses and disclosures of your PHI to carry out treatment, payment, or health care operations, or to limit disclosures to family members, relatives, friends or other persons identified by you who are involved in your care or payment for your care. For example, you could request that the Plan not use or disclose specific information about a specific medical procedure you had. However, the Plan is not required to agree to your request.

Right to Request Confidential Communications. You have the right to request that the Plan communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that

Salt Lake Community College, 10003141, Effective July 1, 2025 we only contact you at work or by mail. The Plan will not ask you the reason for your request, which must specify how or where you wish to be contacted. The Plan will accommodate all reasonable requests to receive communications of PHI by alternative means if you clearly provide information that the disclosure of all or part of your PHI could endanger you.

Right to Inspect and Copy PHI. You have a right of access to inspect and obtain a copy of your PHI (including electronic PHI) contained in the Plan's "designated record set," for as long as the PHI is maintained by the Plan in a designated record set. If you request a copy of the information, the Plan may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request.

"Designated Record Set"…