Medical Insurance
Share Traditional Plan In-Network
Share High Deductible Health Plan
In-Network
STATE-MANDATED BENEFITS
Adoption Indemnity Benefit The benefit is limited to the dollar amount specified by the Utah Department of Insurance in accordance with Utah Code Section 31A-22- 610.1 , as amended .
Clinical Trials Participation in a qualifying clinical trial for the treatment of : » Cancer » Cardiovascular ( cardiac / stroke ) » Surgical musculoskeletal disorders of the spine , hip and knees
Medical Foods TPN and Elemental Formulas are Covered
Benefits will be subject to the same annual deductible and coinsurance / copayment applicable to the pregnancy-maternity services benefit category .
Depending upon where the covered health service is provided , benefits will be the same as those stated under each covered health service category in this benefit summary . 1
Benefits will be subject to the same annual deductible and coinsurance / copayment applicable to the pregnancy-maternity services benefit category .
Depending upon where the covered health service is provided , benefits will be the same as those stated under each covered health service category in this benefit summary . 1
20 % after deductible has been met 20 % after deductible has been met
Mental Health Services — Inpatient 20 % after deductible has been met 20 % after deductible has been met Mental Health Services — Outpatient 20 %, deductible does not apply 20 % after deductible has been met Mental Health Services — Office Visits $ 40 copayment per visit $ 15 after deductible
Neurobiological Disorders Autism Spectrum Disorder Services
Substance Use Disorder Services — Inpatient
Substance Use Disorder Services — Outpatient
PRESCRIPTION DRUG
See Professional , Inpatient , Outpatient , or Mental Health and Chemical Dependency Services
See Professional , Inpatient , Outpatient , or Mental Health and Chemical Dependency Services
20 % after deductible has been met 20 % after deductible has been met
$ 40 copayment per visit 20 % after deductible has been met
Annual Deductible No deductible See medical benefit summary
Retail — Tier 1 Up to 31-day supply
Retail — Tier 2 *** Up to 31-day supply
Retail — Tier 3 *** Up to 31-day supply
Retail — Tier 4 *** Up to 31-day supply
Mail Order — Tier 1 Up to 90-day supply
Mail Order ***— Tier 2 Up to 90-day supply
Mail Order ***— Tier 3 Up to 90-day supply
$ 15 |
$ 7 after deductible |
$ 30 |
$ 21 after deductible |
$ 50 |
$ 42 after deductible |
$ 100 |
$ 100 after deductible |
$ 15 |
$ 7 after deductible |
$ 60 |
$ 42 after deductible |
$ 150 |
$ 126 after deductible |
* Most minor diagnostic tests are covered at 100 %. Some , however , are subject to deductible and coinsurance . Refer to your Certificate of Coverage for specific details .
** Preauthorization may be required .
*** Generic Substitution Required or you pay the copay plus the cost difference between the name brand and generic drug .
Davis Behavioral Health
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