Healthy Premier Gold Copay – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$1,500 per person $1,500 per person
Out-of-pocket max	$7,000 per person $14,000 per family
Metal tier	Gold

Visit Copay

Primary care visit	$25 copay
Specialist visit	$40 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$25 copay
Emergency room	$200 copay after deductible
Ambulance	$250 copay after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	$30 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% coinsurance after deductible
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://doc.uhealthplan.utah.edu/individual/2024/sbc/healthypremier/goldcopay.pdf
Drug and medication plan formulary	https://cbg.adaptiverx.com/webSearch/index?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B6872F239C8ABCF9F40
Search doctor list	https://uuhip.healthtrioconnect.com/public-app/consumer/provdir/entry.page?xsesschk=