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80/20 Hospital Coverage Options

Note: The benefit spreadsheet below reflects "In-Network" benefits payable to participating doctors / hospitals. The intention of the spreadsheet is to point out general differences between the health plan options. This is not a sales brochure or a official brochure from the carriers. It is simply an interpretation of benefits payable by plan design. THEREFORE for details please download the official brochure and application kit from the Plan of your choice.

Benefits

 Base-Level
 Brief -> Medical and Rx deductibles apply to all services first.		   Mid-Level
 Brief -> Medical deductible is waived for office, IHC KidsCare, and IHC InstaCare visits. Rx deductible applies		   High-level
 Brief -> Medical deductible is waived for office, IHC KidsCare, and IHC InstaCare visits. No Rx deductible applies.
           
Office Visit Copay to
PRIMARY Care Provider		 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.
Office Visit Copay to
Secondary Care Provider 		You Pay a $25 Copay AFTER DEDUCTIBLE HAS BEEN MET.   $25 Copay with NO NEED TO MEET DEDUCTIBLE FIRST.    $25 Copay with NO NEED TO MEET DEDUCTIBLE FIRST. 
Calendar Yr. Ded.



Deductible Options Available w/ your quotes ---->

(x number of family members actually insured)

You Choose Your Deductible of
250, 500, 1000 or 2500

250 x 3
500 x 3
1000 x 2.5
2500 x 2

  

You Choose Your Deductible of
250, 500, 1000 or 2500

250 x 3
500 x 3
1000 x 2.5
2500 x 2  

  

You Choose Your Deductible of
250, 500, 1000 or 2500

250 x 3
500 x 3
1000 x 2.5
2500 x 2  
           
Out of Pocket Max.

Single---->
 



Family---->

 

  Single
250 deductible = 2500
500 deductible = 3000
1000 deductible = 3500
2500 deductible = 4000

Family
250 deductible = 5000
500 deductible = 6000
1000 deductible = 7000
2500 deductible = 8000

  

  Single
250 deductible = 2500
500 deductible = 3000
1000 deductible = 3500
2500 deductible = 4000

Family
250 deductible = 5000
500 deductible = 6000
1000 deductible = 7000
2500 deductible = 8000

  

  Single
250 deductible = 2500
500 deductible = 3000
1000 deductible = 3500
2500 deductible = 4000

Family
250 deductible = 5000
500 deductible = 6000
1000 deductible = 7000
2500 deductible = 8000
           
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

Locate your medical deductible to see what your Rx deductible would be for the Base-Level and Mid-Level plans.

No Rx deductibles for the High-Level plans.

Up to a 30-day supply for covered medications; generic substitution required; same copay/coinsurance applies to 90-day maintenance home delivery supply.
Med.
 Plan		 Rx
Deductible		 Rx Classes Rx
Copayment
$250 $100 Generic
Formulary
Non-Form		 $10
25%
50%
$500 $200 Generic
Formulary
Non-Form		 $10
25%
50%
$1000 $400 Generic
Formulary
Non-Form		 $10
25%
50%
$2500 $1000 Generic
Formulary
Non-Form		 $10
25%
50%
 
Med.
 Plan		 Rx
Deductible		 Rx Classes Rx
Copayment
$250 $100 Generic
Formulary
Non-Form		 $10
25%
50%
$500 $200 Generic
Formulary
Non-Form		 $10
25%
50%
 
Med.
 Plan		 Rx
Deductible		 Rx Classes Rx
Copayment
$250 0 Generic
Formulary
Non-Form		 $10
25%
50%
$500 0 Generic
Formulary
Non-Form		 $10
25%
50%
$1000 0 Generic
Formulary
Non-Form		 $10
25%
50%
       
Hospitalization   Base-Level     Mid-Level     High-level
Room & Board You pay 20% after Ded. The insurance carrier pays the difference (80%)   You pay 20% after Ded. The insurance carrier pays the difference (80%)   You pay 20% after Ded. The insurance carrier pays the difference (80%)
Inpatient Physician
Surgeon & Anesthesiologist
           
Maternity   Base-Level     Mid-Level     High-level
Outpatient Care $5,000 Deductible. 100% coverage thereafter.  This deductible does not apply to your maximum out of pocket.   $5,000 Deductible. 100% coverage thereafter.  This deductible does not apply to your maximum out of pocket.   $5,000 Deductible. 100% coverage thereafter.  This deductible does not apply to your maximum out of pocket.
Physician Delivery Fee
Hospital Room & Board 
           
Out-Patient Care    Base-Level     Mid-Level     High-level
Immunizations Covered 100%   Covered  100%   Covered 100%
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
     
Office Visits - Primary Care You Pay a $15 Copay AFTER DEDUCTIBLE HAS BEEN MET.


You pay a $25 Copay AFTER DEDUCTIBLE

You pay nothing AFTER DEDUCTIBLE		   $15 copay - No Ded.   $15 copay - No Ded.
Office Visits - After Hours $15 copay - No Ded. $15 copay - No Ded.
Office Visits Specialist $25 copay - No Ded. $25 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 $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.
         
Out Patient Rehab Therapy -
limit is 20 per calendar year.		 You pay $25 after deductible is met   You pay $25 after deductible is met   You pay $25 after deductible is met
           
Outpatient Hospital Services  

You pay 20% after Ded.

You pay 20% after Ded.

   You pay 20% after Ded.

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 $100 after deductible. You pay $100 after deductible. You pay $100 after deductible.
Supplemental Accident for accidental visit-
Per person/calendar year

1st $1000 covered 100%

 1st $1000 covered 100% 1st $1000 covered 100%
       
Out-of-network Hospital You Pay $200 after deductible. You Pay $200 after deductible.  You Pay $200 after deductible. 
           
IHC InstaCare
Urgent Care Facility		 $25 copay - After Ded.   $25 copay - No Ded.   $25 copay - No Ded.
       
IHC KidsCare
Urgent Care Facility 		 $15 copay - After Ded. $15 copay - No Ded.  $15 copay - No Ded. 
           
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 Dental Max for injury  $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
Does not apply to maximum out of pocket.		 You pay 50% after deductible. Maximum plan payment is $1,500 per calendar year; $5,000 lifetime   You pay 50% after deductible. Maximum plan payment is $1,500 per calendar year; $5,000 lifetime   You pay 50% after deductible. Maximum plan payment is $1,500 per calendar year; $5,000 lifetime
       
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
           
Mental Health & Substance Abuse
Not applied to your maximum out of pocket.		 You pay 50% after deductible. Day limit for inpatient is 10 per calendar year. Visit limit for outpatient is 15 per calendar year.   You pay 50% after deductible. Day limit for inpatient is 10 per calendar year. Visit limit for outpatient is 15 per calendar year.   You pay 50% after deductible. Day limit for inpatient is 10 per calendar year. Visit limit for outpatient is 15 per calendar year.

 

  • As you explore your Health Insurance options in Utah, Benefits Manager is there for you.  As a local agency, we care about our reputation and our Utahan residents and neighbors. We are contracted by these carriers to perform the field underwriting and policy submission at no charge to you. If you can't find the health insurance policy you're looking for, just give us a quick call or e-mail. We can help narrow down which carrier would best meet your needs. 
 
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