In-Network |
Out-of-Network |
|
|
Outpatient Services
Outpatient Facility and Ambulatory Surgical
|
20 % after deductible |
40 % after deductible |
Ambulance ( Air or Ground ) – Emergencies Only |
20 % after deductible |
|
Emergency Room |
$ 75 after deductible |
|
Intermountain InstaCare , Urgent Care Facilities |
$ 30 |
40 % after deductible |
Intermountain KidsCare |
$ 15 |
Not available |
Intermountain Connect Care |
Covered 100 % |
Not available |
Diagnostic Tests : Minor |
Covered 100 % |
40 % after deductible |
Diagnostic Tests : Major |
20 % after deductible |
40 % after deductible |
Home Health , Hospice , Outpatient Private Nurse |
20 % after deductible |
40 % after deductible |
Outpatient Rehab Therapy : Physical , Speech , Occupational |
$ 20 after deductible |
40 % after deductible |
|
Other Benefits
Mental Health and Chemical Dependency Office Visits
|
$ 15 |
40 % after deductible |
Inpatient |
20 % after deductible |
40 % after deductible |
Outpatient |
20 % |
40 % after deductible |
Residential Treatment |
20 % after deductible |
40 % after deductible |
Chiropractic – 800.678.9133 ( 20 visits per plan year ) |
$ 15 |
Not covered |
Maternity and Adoption * |
20 % after deductible |
40 % after deductible |
Infertility - Select Services |
50 % after deducible |
Not covered |
Durable Medical Equipment / Medical Supplies |
20 % after deductible |
40 % after deductible |
Injectable Drugs and Speciality Medications |
20 % after deductible |
40 % after deductible |
|
Prescription Drugs
Retail – Up to 30-day supply
|
||
Tier 1 |
$ 10 |
|
Tier 2 |
$ 25 |
|
Tier 3 |
$ 45 |
|
Tier 4 |
$ 100 |
|
Maintenance Drugs – 90-day supply ( Mail-Order , Retail90 ) | ||
Tier 1 |
$ 10 |
|
Tier 2 |
$ 50 |
|
Tier 3 |
$ 135 |
|
Generic Substitution Required . Generic required or must pay copayment plus the cost difference . | ||