BlueChoices BlueAdvantage Coinsurance - $5,000 Deductible

Health Insurance Utah |Individual BlueChoices BlueAdvantage Coinsurance - $5,000 Deductible

Higher deductibles mean your rates are more affordable.
Prescriptions are covered after you meet your medical deductible.
Additional accident expenses are covered up to $1,000 per person in a calendar year.

Coverage at a Glance

Deductible:	Selected: $5,000 Coins. plan $500 - Copay plan option $1,000 - Copay plan option $2,500 - Coinsurance plan option $5,000 - Coinsurance plan option $7,500 - Coinsurance plan option
Annual OOP Max:	$6,500 per member, $12,000 per family
Lifetime Max:	$2 million per member
Copay:	Not applicable on this plan
Coinsurance:	20% contracted providers, 40% non-contracted
Coinsurance Max:	Not applicable on this plan
Network(s):	Regence Traditional/ValueCare Find a Doctor

	Prescription benefits
	Dental
	Vision
	No Referrals
	Maternity
	Preventive Care
	Alternative Care
	Mental Health

Basic Features

Cost Sharing
Deductibles:	$5,000 per member $10,000 per family
Annual OOP Max:	$6,500 per member per calendar year $12,000 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:	Not applicable on this plan
Coinsurance:	You pay 20% when using contracted providers You pay 40% when using non-contracted providers

Everyday Needs
Prescriptions:	You pay 20% coinsurance after the deductible
Preventive Care:	Deductible and coinsurance Adults and children age 6 and over 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:	After deductible, you pay 20% coinsurance using contracted providers After the deductiible, you pay 40% coinsurance 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

PDF (45k) Benefit Summary: BlueAdvantage Coinsurance $5,000 Deductibl

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
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.