White Plan
Lower Employee PremiumsBlue Plan
Higher Employee PremiumsHospitalization
Annual $125 copay for the first hospital admission. Benefits are paid at 70% for room, board and ancillary charges after initial admission fee. Subsequent hospitalization is paid at 70%. $75 copay per admission for outpatient surgery. Annual $100 copay for the first hospital admission. Benefits are paid at 80% for room, board and ancillary charges after initial admission fee. Subsequent hospitalization is paid at 80%. $50 copay per admission for outpatient surgery. Surgery & Anesthetic
Benefits are paid at 70% for inpatient and outpatient surgery. Hospital physician visits are paid at 70%. Benefits are paid at 80% for inpatient and outpatient surgery. Hospital physician visits are paid at 80%. Medical & Extended Benefits
Annual up-front deductible of $250 per person/ $500 per family. $25 per physician visit. $75 per incident for major diagnostic testing. Annual up-front deductible of $150 per person/$450 per family $20 per physician visit. $50 per incident for major diagnostic testing. Prescriptions
You pay $7 Generic; $25 Brand with NO Generic Equivalent; $35 Brand with Generic Equivalent 35% coinsurance. Maximum out of pocket of $1,200 per person per year. You pay $7 Generic; $25 Brand with NO Generic Equivalent; $35 Brand with Generic Equivalent 35% coinsurance. Maximum out of pocket of $1,000 per person per year. Major Medical
Maximum out of pocket for covered items is $2,000 per person per year/$4,000 per family per year. Maximum lifetime benefit is $2,000,000 per person. Maximum out of pocket for covered items is $1,500 per person per year/$3000 per family per year. Maximum lifetime benefit is $2,000,000 per person.
This option provides coverage when non-preferred facilities or physician's services are used. Services are paid at a lower level than preferred benefits.
Basic Benefits Prosthetics Orthodontics General Examinations, fillings, x-rays, sealants, etc., covered at 80% Dentures, bridges, crowns, etc., covered at 50% Benefits are paid at 50% Maximum benefit per person per contract year on all dental benefits is $1500. Maximum benefit on orthodontics is $1500 per person per lifetime.
|
1695 North Research Park Way · North Logan, Utah 84341 © 2012 Utah State University Research Foundation |