University of Utah Health Insurance Plans

Healthy Preferred Bronze HSA

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,000.00 Family: $14,000 Per Person: $7,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,000.00 Family: $14,000 Per Person: $7,000

Office Visit

Primary Doctor	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month
Generic Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month
Specialty Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Requires Pre-authorization and Medical Case Management.
Inpatient Services	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Requires Pre-authorization and Medical Case Management.

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Benefit Period

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered

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