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BlueChoices BlueAdvantage Copay - $250 Deductible

Health Insurance Utah | Individual BlueChoices BlueAdvantage Copay - $250 Deductible

    • Coverage begins on day one. You can visit the doctor for a simple copay before using your deductible.
    • Lowest deductibles mean additional expenses are paid sooner.
    • Additional accident expenses are covered up to $1,000 per person in a calendar year.

Coverage at a Glance

Deductible:
Annual OOP Max: $2,500 per member, $5,000 per family
Lifetime Max: $2 million per member
Copay: $20
Coinsurance: 20% contracting providers, 40% non-contracting
Coinsurance Max: Not applicable on this plan
Network(s): Regence Traditional/Value Care
Find a Doctor
Yes Prescription benefits
No Dental
No Vision
Yes No Referrals
Yes Maternity
Yes Preventive Care
Yes Alternative Care
Yes Mental Health
 

Basic Features

Cost Sharing
Deductibles:
  • $250 per member
  • $750 per family
Annual OOP Max:
  • $2,500 per member per calendar year
  • $5,000 per family per calendar year
  • These amounts include the deductible.
Coinsurance Max: Not applicable on this plan
Lifetime Max: $2 million paid by Regence per member
Copay:
  • You pay $20 when using contracted providers, no deductible applies
  • After meeting your deductible, you pay $20 and coinsurance when using non-contracted providers
Coinsurance:
  • You pay 20% when using contracted providers
  • You pay 40% when using non-contracted providers
Everyday Needs
Prescriptions:
  • $5 copay for generic medications purchased at the pharmacy
  • You pay 25% when using the formulary
  • You pay 50% when not using the formulary
  • Mail order not available
  • No annual limit
Preventive Care:
  • You pay $20 copay when using contracted providers, no deductible applies
  • After meeting your deductible, you pay $20 copay and coinsurance when using non-contracted providers
  • Adults and children age 6 and over are limited to $300 per member per calendar year
  • Children between 2-5 limited to four visits per year
  • Children 2 and under are limited to ten visits in first 24 months
Vision: Not covered
Office Visits:
  • You pay $20 copay using contracted providers, no deductible applies
  • After meeting your deductible, you pay $20 copay and coinsurance when using non-contracted providers
Diagnostic x-ray services: Deductible and coinsurance
Outpatient Laboratory services: Deductible and coinsurance
Special Needs
Alternative care:
  • Only chiropractic is covered 
  • Deductible and coinsurance
Maternity:
  • Separate $5,000 copayment
  • No coinsurance
  • No deductible applies
Mental Health:
  • Deductible and 50% coinsurance
  • Limited to $1,500 per calendar year
  • Limit does not apply to out-of-pocket maximum
Other considerations
Network(s):

Contracted Providers

  • Regence Traditional
  • ValueCare

Non-Contracted Providers

  • Providers outside the networks above 

Benefit Summary

Rates

About rate changes: We typically adjust rates once a year in July, but the state legislature may mandate changes that affect the cost at other times of the year. Your rate may be adjusted at those times, even if you enrolled for coverage in the previous month.

Medical Exclusions and Limitations

Alternative Care Excluded
Birth Control Included (except for non-prescription contraceptives)
Cosmetic OR Reconstructive Surgery Excluded
Counseling Excluded
Custodial Convalescent Cures Excluded
Dental Services Excluded (accidental injury to sound natural teeth is covered)
Durable Medical Equipment Not limited
Erectile Dysfunction Excluded
Foot Care Excluded
Gastric Procedures such as gastric bypass Excluded
Genetic Services Excluded
Growth Hormone Benefit Excluded
Hearing Treatment Excluded
Home Health Care Not limited
Infertility Excluded
Maternity Care Included after $5,000 copayment
Mental Health Treatment $1,500 limit per enrollee per calendar year
Obesity or Weight Control Excluded
Orthognatic Surgery Excluded
Pre-existing conditions 12 month waiting period
Rehabilitative Care (inpatient) Not limited
Rehabilitative Care (outpatient) $1,500 limit per enrollee per calendar year (includes chiropractic care)
Sterilization 12 month waiting period
Temporomandibular Joint Disorder Excluded
Transplants Not limited
Tobacco Addiction Treatment Excluded
Vision Excluded
You must be continuously covered for at least 12 months before we pay for any of the following
Pre-existing conditions 12 month waiting period
Sterilization 12 month waiting period
Preventative Care
Children — first 24 months 10 exams included
Children — age 2—5 Four exams per enrollee per calendar year
Children — ages 6 and older Limited to $300 per enrollee per calendar year
Adult men and women Limited to $300 per enrollee per calendar year
This does not include all benefits, limitations, exclusions and other terms of coverage (such as eligibility and cancellation provisions) applicable to this plan. Please refer to your contract of a complete list and more in-depth explanation of benefits and the limitations and exclusions that apply.

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