Healthy Premier Bronze w.3 Copays

Health Insurance Plan Details (2024 Plan)

by University of Utah Health Insurance Plans

Monthly Premium

EPO
$ubsidy
Bronze
Deductible
$8,750 /yr
Max Out-of-Pocket
$9,100 /yr

Details

Deductible (per individual) $8,750 /yr
Deductible (per family) $17,500 /yr
Max Out-of-Pocket (per individual) $9,100 /yr
Max Out-of-Pocket (per family) $18,200 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type EPO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $50 and 40% Coinsurance after deductible
Specialist Visit 40% Coinsurance after deductible
Emergency Room 40% Coinsurance after deductible
Inpatient Facility 40% Coinsurance after deductible
Inpatient Physician 40% Coinsurance after deductible
Drug Costs
Generic Drugs $35 Copay
Preferred Brand Drugs $50 Copay
Non-preferred Brand Drugs 50% Coinsurance after deductible
Specialty Drugs 50% Coinsurance after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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