IHC Spreadsheet

Utah Health

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Benefit sheet reflects "In-Network" benefits payable to participating doctors / hospitals.

IHC-Med =800 Physicians
Select-Med =1,900 Physicians
IHC-Care =2,800 Physicians

Benefits	Base-Level	Mid-Level	High-level

Office Visit Copay	You Pay a $15 Copay AFTER DEDUCTIBLE HAS BEEN MET	$15 Copay with no need to meet deductible first	$15 Copay with no need to meet deductible first

Calendar Yr. Ded.	Deductible you choose with your quote	Deductible you choose with your quote	Deductible you choose with your quote

Out of Pocket Max.
Single	3000	3000	3000
Family	6000	6000	6000

Lifetime Max.	Unlimited	Unlimited	Unlimited

Pre-Existing Waiting Period There is a 12 month waiting period for prior medical conditions at the point of effective date here IF you do not have current coverage being replaced by us	12 Month for prior medical conditions. Waived if you are replacing & or given credit if covered under 12 months	12 Month for prior medical conditions. Waived if you are replacing & or given credit if covered under 12 months	12 Month for prior medical conditions. Waived if you are replacing & or given credit if covered under 12 months


Prescription Coverage's	Base-Level	Mid-Level	High-level
Generic	Must meet a $100 deductible first then you pay:	Must meet a $200 deductible first then you pay:	$5 generic
Name Brand	$5 generic	$5 generic
Non-Preferred	25% of NB	25% of NB	25% of (NB) Name Brand
	50% of NF	50% of NF
			50% pf (NF)
			Nonpreferred Brand Name

Hospitalization	Base-Level	Mid-Level	High-level
Room & Board	You pay 20% after Ded. The insurance carrier pays the difference.	You pay 20% after Ded. The insurance carrier pays the difference.	You pay 20% after Ded. The insurance carrier pays the difference.
Inpatient Physician
Surgeon & Anesthesiologist

Maternity	Base-Level	Mid-Level	High-level
Outpatient Care	$5,000 Deductible. 100% coverage thereafter	$5,000 Deductible. 100% coverage thereafter	$5,000 Deductible. 100% coverage thereafter
Physician Delivery Fee
Hospital Room & Board

Out-Patient Care	Base-Level	Mid-Level	High-level
Immunizations	Covered 100%	Covered 100%	Covered 100%
Doctor Office Coverage's:
Preventative Care-By Primary Doctor	You Pay a $15 Copay AFTER DEDUCTIBLE HAS BEEN MET	$15 copay - No Ded.	$15 copay - No Ded.
Annual Physical		100% coverage	100% coverage
Immunizations		No Limit Maximum	No Limit Maximum

Office Visits - Primary Care	Covered 100% AFTER DEDUCTIBLE HAS BEEN MET	$15 copay - No Ded.	$15 copay - No Ded.
Office Visits - After Hours		$15 copay - No Ded.	$15 copay - No Ded.
Office Visits Specialist		$15 copay - No Ded.	$15 copay - No Ded.
Minor Lab/X-ray w/ mammography		100% No Deductible	100% No Deductible

Major Lab/X-ray w/ CT scan, MRI/MRA	You pay 20% after Ded.	You pay 20% after Ded.	You pay 20% after Ded.

Physiotherapy -	No max	No max	No max
Physiotherapy -	No max	No max	No max
Providers Office -	Deductible met than	$15 copay - No Ded.	$15 copay - No Ded.
Outpatient Facility	You pay 20% after Ded.	You pay 20% after Ded.	You pay 20% after Ded.

Out Patient Surgery	You pay 20% after Ded.	You pay 20% after Ded.	You pay 20% after Ded.

Outpatient Hospital Services	You pay 20% after Ded.	You pay 20% after Ded.	You pay 20% after Ded.
Chemotherapy, Radiation therapy
Kidney Dialysis

Eye Exams - Optometrist	100% Covered	100% Covered	100% Covered

Emergency Care	Base-Level	Mid-Level	High-level

Emergency Room Visit	Full Coverage	Full Coverage	Full Coverage

In-network Hospital	You pay $25 plus 20% coinsurance after Ded.	You pay $25 plus 20% coinsurance after Ded.	You pay $25 plus 20% coinsurance after Ded.
Accidental Visit
	You pay $75 plus 20% coinsurance after Ded.	You pay $75 plus 20% coinsurance after Ded.	You pay $75 plus 20% coinsurance after Ded.


Out-of-network Hospital
Accidental Visit
Non - Accidental Visit


IHC Insta Urgent Care	$25 copay - After Ded.	$25 copay - No Ded.	$25 copay - No Ded.
	$15 copay - After Ded.	$15 copay - No Ded.	$15 copay - No Ded.
IHC Kids Care Urgent Care

Ambulance, Paramedics	You pay 20% after Ded.	You pay 20% after Ded.	You pay 20% after Ded.
Air Ambulance	You pay 20% after Ded.	You pay 20% after Ded.	You pay 20% after Ded.

Other Benefits	Base-Level	Mid-Level	High-level

Medical Supplies	You pay 20% after Ded.	You pay 20% after Ded.	You pay 20% after Ded.
Accident-Related Dental Services	You pay 50% after Ded.	You pay 50% after Ded.	You pay 50% after Ded.
Lifetime Max	$1,000	$1,000	$1,000

Allergy Conditions
Testing & Treatment	$15 copay -After you meet your ded.	$15 copay - No Ded.	$15 copay - No Ded.
Injections	You pay 20% after Ded.	You pay 20% after Ded.	You pay 20% after Ded.

Serum:	You pay 20% after Ded.	You pay 20% after Ded.	You pay 20% after Ded.

Infertility Treatment -	Diagnostic Only	Diagnostic Only	Diagnostic Only
Limited To:
Yearly Maximum Benefit	$1,500	$1,500	$1,500
Lifetime Maximum Benefit	$5,000	$5,000	$5,000

Adoption Benefit Payable to You	$3,155 Per Adoption	$3,155 Per Adoption	$3,155 Per Adoption

Chiropractic Care -	Not Covered	Not Covered	Not Covered

Maximum Visits per year

Mental Health	Inpatient or Out	Inpatient or Out	Inpatient or Out
Substance Abuse	50% after Ded.	50% after Ded.	50% after Ded.

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