Perry City Payment Approval Report Page: 1Report dates: 3/19/2018-4/4/2018 Apr 05, 2018 04:37PM

Report Criteria:Detail report.Paid and unpaid invoices included.

Vendor Vendor Name Invoice Number Description Invoice Date Net Amount Paid Date Paid VoidedInvoice Amount

Brigham City Corp.6106 Brigham City Corp. 4/03/2018 interlocal storm water 04/01/2018 117.60 117.60 04/03/20186106 Brigham City Corp. 4/03/2018 walmart sales tax 04/01/2018 17,105.44 17,105.44 04/03/2018

Total Brigham City Corp.: 17,223.04 17,223.04

Enerspect Medical Solutions12313 Enerspect Medical Solutions 37730 1st Responders 03/23/2018 3,004.70 3,004.70 04/03/2018

Total Enerspect Medical Solutions: 3,004.70 3,004.70

Jones & Associates11552 Jones & Associates 18348 miscellaneous 04/01/2018 989.00 989.00 04/03/201811552 Jones & Associates 18348 streets 04/01/2018 513.00 513.00 04/03/201811552 Jones & Associates 18348 Culinary Water 04/01/2018 319.25 319.25 04/03/201811552 Jones & Associates 18348 Well #1 04/01/2018 171.00 171.00 04/03/201811552 Jones & Associates 18348 G.I.S. 04/01/2018 219.00 219.00 04/03/201811552 Jones & Associates 18349 Development Reviews 04/01/2018 2,432.00 2,432.00 04/03/2018

Total Jones & Associates: 4,643.25 4,643.25

Lucky Dog Recreation12335 Lucky Dog Recreation UT0318-2308 Dog Stations/Park 03/16/2018 141.00 141.00 03/28/201812335 Lucky Dog Recreation UT0318-2308 Dog Stations/Park 03/16/2018 2,431.50 2,431.50 03/28/201812335 Lucky Dog Recreation UT0318-2308 Dog Stations/Park 03/16/2018 2,431.50 2,431.50 03/28/2018

Total Lucky Dog Recreation: 5,004.00 5,004.00

Rocky Mountain Power2501 Rocky Mountain Power 3/28/2018 WWTP Power 03/15/2018 4,370.79 4,370.79 03/28/20182501 Rocky Mountain Power 4/04/2018 power bill 03/22/2018 1,713.44 1,713.44 04/04/20182501 Rocky Mountain Power 4/04/2018 power bill 03/22/2018 77.61 77.61 04/04/20182501 Rocky Mountain Power 4/04/2018 power bill 03/22/2018 4,204.70 4,204.70 04/04/20182501 Rocky Mountain Power 4/04/2018 power bill 03/22/2018 105.94 105.94 04/04/20182501 Rocky Mountain Power 4/04/2018 power bill 03/22/2018 368.26 368.26 04/04/2018

Total Rocky Mountain Power: 10,840.74 10,840.74

Utah Local Governments Trust10333 Utah Local Governments Trust 3/20/2018 workers compensation 03/19/2018 2,967.35 2,967.35 03/20/2018

Total Utah Local Governments Trust: 2,967.35 2,967.35

Zions Bank11510 Zions Bank 4/04/2018 Utopia 03/26/2018 9,706.14 9,706.14 04/04/2018

Total Zions Bank: 9,706.14 9,706.14

Grand Totals: 53,389.22 53,389.22

Perry City Payment Approval Report Page: 2Report dates: 3/19/2018-4/4/2018 Apr 05, 2018 04:37PM

Vendor Vendor Name Invoice Number Description Invoice Date Net Amount Paid Date Paid VoidedInvoice Amount

Dated: ______________________________________________________

Mayor: ______________________________________________________

City Council: ______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

City Recorder: _____________________________________________________

Report Criteria:Detail report.Paid and unpaid invoices included.

How does someone develop neurofibromatosis? Half of the people who develop NF1 or NF2 inherit it from a parent. The others develop it by chance, as the result of a spontaneous change in a specific gene in an egg or sperm cell. Every person affected by NF1 or NF2 has a 50 percent chance of passing the condition on to their offspring. Schwannomatosis is less well understood, but the majority of cases appear to occur by chance, not because they are inherited.

Is there a blood test for NF?A blood test is available for all three forms of NF. This test determines if someone has the gene responsible for these disorders. These tests are not done routinely because a clinical diagnosis (based on observable signs of NF) is considered reliable in most cases. Sometimes genetic testing may be used to confirm a clinical diagnosis. The decision of whether or not to pursue genetic testing is a personal one. It is important to speak with a qualified genetic health care professional about the appropriate risks, benefits, and limitations of testing.

NEUROFIBROMATOSIS

QA&Frequently Asked QuestionsAbout NF

Can NF be cured?At this time, there is no approved cure for NF, but a number of promising NF clinical trials are under way. As researchers continually learn more about the underlying causes of NF and what makes tumors grow, we get closer to the development of effective treatments for NF. We are hopeful that we will be able to offer FDA approved drugs for NF in the near future.

What should someone do if they think they have NF? Only a trained health-care professional familiar with the condition can make a clinical diagnosis of NF. If you think you or your child has NF, contact a doctor for an evaluation. You can find a list of NF specialty clinics across the country by contacting the Children’s Tumor Foundation at 800-323-7938 or by visiting the CTF website: www.ctf.org.

What other resources are available?The Children’s Tumor Foundation, a nonprofit organization dedicated to finding effective treatments for NF through support of medical research, is the oldest and largest national foundation for NF in the United States. You can find information on NF, support groups, NF specialists, research news, educational events, family events, and many other ways to support the NF community by visiting our website: www.ctf.org.

120 Wall Street, 16th Floor New York, NY 10005www.ctf.org | info@ctf.org 1-800-323-7938

Insta @childrenstumor

@childrenstumor

childrenstumor

children’s-tumor-foundation

ctforg

What is neurofibromatosis (NF)?Neurofibromatosis (NF) is a term for three genetic disorders, NF1, NF2, and schwannomatosis. NF can cause tumors to grow on nerves throughout the body.

What are the types of neurofibromatosis?Three types of neurofibromatosis exist:

Neurofibromatosis 1 (NF1): This is the most common type of neurofibromatosis. NF1 occurs in about 1 in 3,000 people. NF1 is characterized by six or more café-au-lait (light brown) spots and neurofibromas (small benign tumors) on or under the skin. About half of people with NF1 also have learning challenges. Some patients with NF1 develop softening and curving of bones and curvature of the spine (scoliosis). Occasionally, tumors may develop in the brain, on cranial (brain) nerves, or on the spinal cord. While NF tumors are generally not cancerous, they may cause health problems by pressing on nearby body tissues. Sometimes a benign tumor may become malignant (cancerous), but 90 percent of people with NF1 will never develop a malignant tumor. NF1 is usually diagnosed in childhood.

Neurofibromatosis 2 (NF2): This type of neurofibromatosis occurs in about 1 in 25,000 people. NF2 is usually diagnosed with the onset of hearing loss or tinnitus (ringing in the ears), which is the result of benign tumors that form on the vestibular nerve in the brain. The hallmark of NF2 is the appearance of bilateral vestibular schwannomas, benign tumors on both sides of the vestibular nerve. People with NF2 may also develop schwannomas in other parts of the body, or may develop other types of benign brain or spinal tumors. Many people with NF2 may develop cataracts and other kinds of eye abnormalities, although these are usually treatable. NF2 is usually diagnosed in young adulthood.

Schwannomatosis: This type of neurofibromatosis affects about 1 in 40,000, or even fewer, people. Individuals with schwannomatosis may develop benign tumors, called schwannomas, on nerves anywhere in the body. These tumors may cause pain that may be hard to manage. Schwannomatosis is usually diagnosed in adulthood.

Is neurofibromatosis the same as Elephant Man’s disease?No. Neurofibromatosis is not Elephant Man’s disease. For many years, scientists believed that Joseph Merrick, the so-called “Elephant Man,” had NF1. However, in 1986, it was established that he had Proteus syndrome, an extremely rare condition.

Can one type of NF turn into another?No. The three types of NF are all distinct disorders.

Will NF affect someone’s life expectancy?Most people with NF will have a near normal life expectancy. Some patients develop more serious complications that may shorten their lives.  

Is there any way to predict how severe a person’s NF will be?It depends. The type and severity of the symptoms of NF1 vary from person to person, and cannot be predict-ed in advance. Even when the condition is inherited, a child’s symptoms may be different from those of the af-fected parent. When NF2 is inherited, however, a child’s symptoms tend to be similar to those of the affected parent. When NF2 occurs spontaneously, the type of genetic mutation can predict to a certain extent what the course of the disorder will be. It is not possible to predict the course of schwannomatosis at this time.

120 Wall Street, 16th Floor New York, NY 10005www.ctf.org | info@ctf.org 1-800-323-7938

Insta

Connecting Researchers

To make a donation, become involved, or learn

about Foundation activities in your area, please

visit our website at ctf.org.

Connecting Patients

we ensure that the Best nF

PrOFessIOnaLs FrOM arOunD

the wOrLD are COLLaBOratInG

On the Latest nF researCh.

NF CoNFereNCe Our annual gathering of NF researchers and clinicians advances collaboration, research, and care for people with NF.

NF CoNsortia Collaborations accelerate research development through synodos for NF1, synodos for NF2, and synodos for schwannomatosis.

we are COMMItteD tO BrInGInG

the Best nF Care tO PatIents.

NF registry Join the thousands of people who have enrolled in the NF Registry, a critical tool in matching NF patients to clinical trials.

To join or learn more, go to nfregistry.org.

NF CliNiC Network More than 10,000 patients a year visit our NF Clinic Network.

aBOut the children’s tumor foundation

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aCrOss the COuntrY, the ChILDren’s tuMOr FOunDatIOn PrOVIDes suPPOrt tO nF PatIents anD FaMILIes, raIsInG nF awareness anD FunDs FOr researCh.

Connecting Communities

NF eNduraNCe Professional and amateur athletes run, bike, and swim in endurance events to raise awareness and funds for NF research.

raCiNg4researCh Professional auto racing is the vehicle to raising funds and awareness in an exciting race weekend.

iN your CoMMuNity The Foundation works to strengthen bonds and create networks with NF families, as well as connect them to vital resources.

NF CaMp Young people with NF gather in the summer for fun, friendship, and a lifetime of memories.

NF ForuM Hundreds of NF families learn about the latest in NF research and build supportive relationships.

about neurofibromatosisNeurofibromatosis, or NF, is a genetic disorder that affects 1 in every 3,000 people. It causes tumors to grow on nerves throughout the body, and can lead to deafness, blindness, disfigurement, bone abnormalities, learning disabilities, disabling pain, and cancer. NF occurs in all populations equally, and there is not yet a cure.

about children’s tumor foundationFounded in 1978, the Children’s Tumor Foundation (CTF) began as the first grassroots organization solely dedicated to finding treatments for NF. Today, CTF is a highly recognized national nonprofit foundation, the leading force in the fight to end NF, and a model for other innova tive research endeavors.

our Mission Drive research, expand knowledge, and advance care for the NF community.

our VisionEnd NF.

NF walk Local NF Walks across the country bring families and friends together to raise funds and build community.

MUNICIPAL CLERKS WEEK

• Maintains the official council minutes, ordinance books,records and documents.

• Indexes all official actions of council.• Issues licenses and permits.• Processes contracts and agreements.• Keepers of community history and vital records.• Receives, distributes and files correspondence from citizens and

other governmental agencies.• Administers elections, registration and voting. It takes Municipal Clerks months to

organize and prepare this key element in the democratic process which must bedone correctly for the whole system to work!

• Acts as a key liaison between local government and its citizens.• Handles significant financial responsibilities including preparation of tax rolls,

special assessments and budgets.• Provides central services such as personnel, purchasing, etc.

One of local government’s deep-rooted titles is the Municipal Clerk, and their duties have expanded over the years. Today, modern technology assists them with their increasing responsibilities. IIMC provides the tools to be sure your Municipal and Deputy Clerks can properly operate new computer applications, are current regarding the latest records man-agement techniques and other relevant information, and they may return to the classroom to increase their knowledge of these issues, to learn new material and sharpen old skills- all in order to give you the best service possible!

IIMC has sponsored Municipal Clerks Week since 1969. In 1984 and in 1994, Presidents Ronald Reagan and Bill Clinton, respectively, signed a Procla-mation officially declaring Municipal Clerks Week the first full week of May and recognizing the essential role Municipal Clerks play in local government. During this week, Municipal Clerks throughout the world will host open houses and tours of the Municipal Clerk’s office, visit local schools and participate in other various events.

May 6 - 12, 2018

Ask your Clerk about it today!

Although it is one of the oldest positions in local government, few people realize the vital services Municipal and Deputy Clerks perform for their community. Primarily, they act as the cornerstone of their council. Do you know what your Municipal Clerk does for your Community? Here’s just a few of the many duties your Municipal Clerk may do:

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NATIONAL POLICE WEEK

Sunday, May 13 - Saturday, May 19, 2018

In 1962, President Kennedy proclaimed May 15 as National Peace Officers Memorial Day and the calendar week in which May 15 falls, as National Police Week. Established by a joint resolution of Congress in 1962, National Police Week pays special recognition to those law enforcement officers who have lost their lives in the line of duty for the safety and protection of others.

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National Police Week is a collaborative effort of many organizations dedicated to honoring America's law enforcement community. The principal organizers of National Police Week include:

• National Law Enforcement Officers Memorial Fund (NLEOMF), which produces the annual Candlelight Vigil.Phone: (202) 737-3400 | Email: vigil@nleomf.org

• Fraternal Order of Police/Fraternal Order of Police Auxiliary(FOP/FOPA), which organize the Peace Officers Memorial Day Service at the U.S. Capitol.www.policeweek.org

• Concerns of Police Survivors (C.O.P.S.), which holds the National Police Survivors' Conference.Phone: (573) 346-4911First year survivors, call: (800) 784-2677 | Email: cops@nationalcops.org

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901 E Street, NWSuite 100Washington, DC 20004-2025202.737.3400 fax 202.737.3405 info@nleomf.org

The National Law Enforcement Officers Memorial is located on E Street, between 4th and 5th Streets, NW, in Washington, DC.

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WHEREAS, public works professionals focus on infrastructure, facilities and services that are of vital importance to sustainable and resilient communities and to the public health, high quality of life and well-being of the people of [insert state]; and,

WHEREAS, these infrastructure, facilities and services could not be provided without the ded-icated efforts of public works professionals, who are engineers, managers and employees from state and local governments and the private sector, who are responsible for rebuilding, improving and protecting our nation’s transportation, water supply, water treatment and solid waste systems, public buildings, and other structures and facilities essential for our citizens; and,

WHEREAS, it is in the public interest for the citizens, civic leaders and children in the (STATE NAME) to gain knowledge of and to maintain a progressive interest and understanding of the im-portance of public works and public works programs in their respective communities,

WHEREAS, the American Public Works Association has celebrated the annual National Public Works Week since 1960,

RESOLVED, I, (ADD NAME AND TITLE), do hereby designate the week May 21 -27, 2018 as National Public Works Week; I urge all our people to join with representatives of the American Public Works Association and government agencies in activities, events and ceremonies designed to pay tribute to our public works professionals, engineers, managers and employees and to recog-nize the substantial contributions they make to protecting our national health, safety, and quality of life.

IN WITNESS WHEREOF, I have hereunto set my hand and caused the Seal of the State (to be affixed),

DONE at the City of [insert city], [insert State] this ________the day of ________ 2018.

[Insert name][SEAL]

National Public Works Week 2018 Proclamation (SAMPLE)

T his file provides live links to important information about PEHP’s medical, pharmacy, and dental plans, ancillary programs, and healthcare reform. It also includes your 2018-19 rates and enrollment form.

Follow these five easy steps to enroll your agency:

Review the Renewal Timeline at the bottom of this page.

Review your agency’s rates. (Page 2)

Review benefit and administrative changes and options. (Pages 3-4)

Sign up to attend an LGRP Payroll Cordinators Meeting. (Page 5)

Review the 2018-19 Benefit Selection Form. You’ll find your current benefit selections. If you wish to maintain your current benefits, just check the box at the top of the form, sign it and return it. (Pages 6-7)

Welcome to Open Enrollment 2018-19

Where to?This document contains the following information:» Renewal Rates

» Benefits Changes and Reminders

» Payroll Coordinators Meetings

» Benefit Selection Form

Online InfoClick here to find details about the following:» Medical benefits» Dental benefits» Pharmacy» Vision» PEHP FLEX$

Renewal TimelineApril 2: Open Enrollment period opens.

April 10-25: Payroll Coordinators Meetings for benefits managers, providing detailed information and Q&A opportunities on the upcoming renewal.

June 1: Benefits Selection Form deadline.

June 8: Open Enrollment period closes.

July 1: New plan year begins.

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WWW.PEHP.ORG

Rate SheetPerry City

LOCAL GOVERNMENTS RISK POOL: Rate Renewal July 1, 2018 to June 30, 2019

CURRENT MEDICAL PLANS

Advantage & Summit LGRP Traditional Option 4Single Double Family

Current $464.08 $960.64 $1,299.42New $494.26 $1,023.08 $1,383.88

Renewal: 6.5%

Advantage & Summit LGRP STAR Option 1Single Double Family

Current $447.56 $926.42 $1,253.12New $473.78 $980.72 $1,326.58

Renewal: 5.9%

Overall Medical Renewal: 6.1%

Summit Exclusive Network Discount: -8.1%Capital Network Discount: -13.3%

CURRENT DENTAL PLAN

Traditional Dental Care (No Waiting Period)Single Double Family

Current $51.84 $70.90 $107.32New $51.84 $70.90 $107.32

Renewal: 0.0%

Please talk to your PEHP Client Services representative about rates for alternative plan and network options.

WWW.PEHP.ORG

WWW.PEHP.ORG

Benefit Changes – All Plans

» Expanded Network OptionsGroups who only offer the Advantage Network are eligible for the Advantage Exclusive Network (same network, lower cost). Groups who only offer the Summit Network continue to be eligible for the Summit Exclusive Network. Also available is the Capital Network. Please talk to your PEHP Client Services Representative about these new options.

» New IRS Minimums for STAR Option 1 only: Previous Change Individual Family Individual FamilyDeductible $1,300 $2,600 $1,350 $2,700OOP Max $2,600 $5,200 $2,700 $5,400

» Embedded Maximums on STAR PlansPer federal law, effective Jan. 1, 2018, the STAR Option 3 and STAR Option 5 plan embedded individual out-of-pocket maximums increase to $7,350 from $7,150.

» Durable Medical EquipmentPrior to July 1, 2018, sleep disorder equipment (CPAP, BIPAP machines) required a 10-month rent-to-purchase. Starting July 1, members can now purchase sleep disorder equipment without a required rental period. The $2,500 maximum for the equipment and supplies has also been altered to one machine in a 5-year period, and supplies limited to $325 per plan year. All prior limits will not apply and new limits will reset on July 1.

Reminders

» Medicare SupplementAs a reminder, all of PEHP’s prescription drug plans are creditable. PEHP’s Medicare Part D Prescription Drug Plans are creditable.

Employers need to disclose to CMS that prescription drug coverage is creditable annually no later than 60 days from the beginning of a plan year (contract year, renewal year). Do so at this link.

» PharmacyPEHP’s Preferred Drug List is modified periodically with changes based on recommendations from PEHP’s Pharmacy and Therapeutics Committee.

» Message CenterVisit the Message Center at www.pehp.org. This tool allows PEHP to send announcements, messages, and forms that directly relate to our members’ needs and concerns.

WWW.PEHP.ORG

Benefit Changes & Reminders

WWW.PEHP.ORG

Optional BenefitsAutism Benefit

» For Groups of 51+ employees An autism benefit is now available. The rates

provided with in this packet do not include this benefit. The cost to add this benefit is listed below. Check the box on the Benefits Selection Form if you choose not to add this benefit.

Additional Costs:100+ employees = 0.5%50-99 employees = 0.75%

» For Groups up to 50 employeesIf you are interested in adding this benefit talk to your Client Services Representative for more information.

» Education agencies onlyAs defined by the Utah Legislature, coverage of behavior health therapy for the treatment of Autism is mandatory for education agencies with 50+ full-time equivalent employees, and must be added as a benefit to the employer health plan. The State law follows the federal ACA regulations concerning who is an “applicable large employer” for determining how many full-time equivalent employees an employer maintains and whether that employer is subject to this Autism treatment mandate. Talk to your Client Services Representative for questions or more information.

» Find more details about the Autism Benefit

STAR Plan Preventive Drug Coverage

» Now you can provide medication coverage for employees on the STAR Plan before they meet their deductible. This benefit covers certain preventive medications at regular benefits prior to deductible. See the complete list of covered drugs. The cost to add this benefit varies by plan, but ranges from 0.71% to 1.27% in additional premium. If you’re interested let us know and we’ll send you updated rates for 2018-2019.

myWellness Tracker

» myWellness Tracker is available beginning July 2018. The goal of this wellness add-on is to help employees and spouses create healthy habits. Employees can choose from a variety of challenges, track their progress, and earn points for completing activities.

» Cash IncentivesAt the end of the plan year PEHP will send checks to those who have reached reward levels. Participants can earn $50 per level up to $150. FICA tax will be withheld from payments. The cash rewards for this program are in addition to all other rebates earned through Healthy Utah, PEHP Wellness improvement rebates, WeeCare, and Health Coaching.

» CostThe cost to add this program is 0.32% of premium. This covers the PEPM fee paid to WellRight as well as the anticipated rewards that will be paid out.

» Find more details about myWellness Tracker

Tuesday, April 10Cache County Admin. Bldg

Multipurpose Room179 N. Main, Logan

Wednesday, April 11Sevier County Admn. BldgTraining Room (Basement)

250 N. Main, Richfield

Tuesday, April 17Washington City Community Center

Party Room350 Community Center Dr., Washington City

Tuesday, April 17Central Utah Water Conservancy

District Offices355 W. University Parkway, Orem

Thursday, April 19URS/PEHP Offices

URS Basement Conference Room540 E. 200 S., Salt Lake City

Wednesday, April 25Vernal City OfficesCommunity Room374 E. Main, Vernal

Program Agenda

Registration Required Contact: Brian Alm 801-366-7796 • brian.alm@pehp.org

Who Should Attend? Personnel responsible for Medical, Dental, Vision, Life, & Retirement Benefits

The half-day meeting is FREE and will include information on:» PEHP Medical Networks

» STAR Plans

» Healthy Utah

» FLEX$

» Pharmacy

» Utah Retirement Systems

» Medical

» Dental

» Vision

» Life/AD&D Insurance

» Online Enrollment

» Health Savings Accounts

» Healthcare Reform

» Cost & Quality Tools

» Breakfast & Lunch Provided

Payroll Coordinators Meeting

9 a.m. Sign-in and Welcome

9:10 a.m. Utah Retirement Systems

9:40 a.m. EyeMed

9:50 a.m. Opticare

10 a.m. Break

10:15 a.m. PEHP Benefits

WWW.PEHP.ORG

PHARMACY BENEFITSOPTION A OPTION C OPTION G

OPTION B OPTION D

STAR EXPANDED PREVENTIVE COVERAGE (Optional. See Page 4 for details.)

MEDICAL BENEFITS: Summit Exclusive (SX), Summit (S), Advantage Exclusive (AX), Advantage (A), Preferred (P) & Capital (C) Networks

Option 1 Option 2 Option 3 Option 4 Option 5

Traditional – In- & Out-of-Network Providers

Traditional – In-Network Providers only

STAR (In- & Out-of-Network Providers)*

Please mark the benefit plan(s) your agency will offer to employees for the plan year starting July 1, 2018. This form must be filled out completely and returned to PEHP by June 1, 2018.Questions? Contact Gabriel Woodruff-Pace at 801-366-7530.

Email: gabriel.woodruff-pace@pehp.org | Fax: 801-245-7530

Mail: Gabriel Woodruff-Pace, PEHP, 560 East 200 South, Salt Lake City, Utah 84102-2004

Please return completed form by June 1, 2018

2018-19 Benefit Selection Form

(Please mark a)

ONLINE ENROLLMENTThe PEHP online enrollment portal will open the date we receive your Selection Form, and will close Friday, June 8, 2018.

DENTAL BENEFITSPreferred Dental Care (With waiting period) (PFD-W)5-year Missing Tooth Waiting Period / 6-month Orthodontic & Prosthodontic

Preferred Dental Care (No waiting period) (PFD)

Traditional Dental Care (No waiting period) (TDC)

Premium Dental Care (No waiting period) (PDC)

(Please mark a)

*If offering a STAR plan, please list your Health Savings Account (HSA) vendor:

(Please mark a)

Health Equity Other:

ANCILLARY PRODUCTSPEHP FLEXIBLE SPENDING ROLLOVER ACCOUNT (FLEX$) GRACE PERIOD

PEHP GROUP TERM LIFE & ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) PLANS

LONG-TERM DISABILITY (LTD)

AUTISM BENEFIT (for groups up to 50)

AUTISM OPT-OUT (for groups of 51+)

LEGAL GUARDIANSHIP

myWELLNESS TRACKER

(Please mark a)

YOUR CURRENT BENEFITS: Perry CityNO CHANGES: Check this box if you wish to maintain

current benefits. You must fill out the ACA Reporting section, if applicable.

VISION BENEFITSEyeMed – PEHP Full (EYE-H)

EyeMed – PEHP Eyewear Only (EYE-F)

Opticare of Utah – 10-175/150C Full Benefits (OPT-FULL)

Opticare of Utah – 175/150C Eyewear Only (OPT-EYE)

(Please mark a)

See page 2 of form for ACA Reporting and

Agency Information sections

3/9/18

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

S AX ASX P C

MARKETING USE ONLY

OE Start Date: OE End Date: Form Verified:

Medical: SUM4T, ADV4T, SSTAR1,

ASTAR1

Dental: TDC

Vision: NO

Pharmacy: C

Life/AD&D: NO

FLEX$: FLEX$-GP

LTD: YES

Autism: NO

Legal Guardianship: NO

AGENCY NAME

AGENCY INFORMATION

CONTACT PERSON TITLE

TOTAL NUMBER OF EMPLOYEES (INCLUDING NON-BENEFITED)

SIGNATURE PHONE NUMBER

EMAIL ADDRESS

/ /DATE

I certify that all the information on this form is true and correct. All other terms and conditions of the Employer Health Insurance Agreement and Dental Agreement shall remain in effect.

ACA GROUP REPORTING

New Hire Waiting Period:

Date of Hire

Month after Date of Hire

30 days after Date of Hire

60 days after Date of Hire

90 days after Date of Hire

Other (Can’t be more than 90 days)

Please define:

You only need to complete this if you are an applicable large employer (50+ full-time employees) and have elected to have PEHP do your IRS ACA reporting.

What is the premium cost share percentage for a single coverage, 30-hour-per-week employee?

If different, what is the cost share for a40-hour-per-week employee:

Is there any other premium share that applies to full-time (30+ hours per week) employees not listed above? (i.e. administrators, classifieds, teachers)

Yes, ____________% No

What is the lowest annual salary for a full-time employee? $_______________

(If this doesn’t meet affordability standards, we may contact you for more information.)

2018-19 Benefit Selection Form Page 2

Affordability:

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