Healthy Premier Gold Copay

42261UT0060001
Gold
EPO

Healthy Premier Gold Copay is a Gold EPO plan by University of Utah Health Plans.

IMPORTANT: You are viewing the 2024 version of Healthy Premier Gold Copay 42261UT0060001. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Healthy Premier Gold Copay is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Healthy Premier Gold Copay 42261UT0060001.
Insurer: University of Utah Health Plans
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 42261UT0060001

Cost-Sharing Overview

Healthy Premier Gold Copay offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Healthy Premier Gold Copay?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Healthy Premier Gold Copay offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions: See Plan Document
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Healthy Premier Gold Copay covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description: Emergent Only
Out of Service Area Coverage: No
Out of Service Area Coverage Description: Emergent Only
National Network: No

Additional Benefits and Cost-Sharing

Healthy Premier Gold Copay includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$25.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$25.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%6.0 Months per 3 Years Requires Pre-authorization and Medical Case Management.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$25.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Benefit Period
Emergency Room Services
Covered
$200.00 Copay after deductible Not Applicable$200.00 Copay after deductible Not Applicable
Emergency Transportation/Ambulance
Covered
$250.00 Copay after deductible Not Applicable$250.00 Copay after deductible Not Applicable
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Benefit Period Requires Pre-authorization and Medical Case Management.
Prenatal and Postnatal Care
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Office Visits will be subject to a Copay, All other outpatient services are subject to the deductible and coinsurance
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Requires Pre-authorization.
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Office Visits will be subject to a Copay, All other outpatient services are subject to the deductible and coinsurance
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Requires Pre-authorization.
Generic Drugs
Covered
$15.00 Not ApplicableNot Applicable 100.00%30.0 Item(s) per Month
Preferred Brand Drugs
Covered
$30.00 Not ApplicableNot Applicable 100.00%30.0 Item(s) per Month
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Item(s) per Month
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Item(s) per Month
Outpatient Rehabilitation Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Benefit Period Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year
Habilitation Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Benefit Period Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year
Chiropractic Care
Durable Medical Equipment
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% DME over $1000, rentals, that exceed 60 days, or as indicated in Appendix A of the Master Policy require Pre-authorization.
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNo Charge Not Applicable1.0 Visit(s) per Benefit Period
Eye Glasses for Children
Covered
No Charge Not ApplicableNo Charge Not Applicable1.0 Item(s) per Benefit Period Lenses only.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Benefit Period Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Benefit Period Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00% Benefit should mirror preventive care/screening/immunization.
Laboratory Outpatient and Professional Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Orthodontia – Child
Major Dental Care – Child
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Dialysis
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Charges for office visits in connection with repetitive injections are not covered. Sublingual or colorimetric allergy testing.
Chemotherapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Must be for the diagnosis of diabetes.
Prosthetic Devices
Infusion Therapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy.
Gender Affirming Care
Inherited Metabolic Disorder – PKU
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Autism Spectrum Disorders
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Healthy Premier Gold Copay preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Healthy Premier Gold Copay including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Healthy Premier Gold Copay?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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