Download CHOOSE YOUR MEDICAL COVERAGE

CHOOSE YOUR MEDICAL COVERAGE
OPEN ENROLLMENT 2016
Deseret Premier, Deseret Select, Deseret Value, Deseret Protect
It’s open enrollment—time to think about the generous, yet
affordable, 2016 medical coverage made available to you by
your employer. Please keep in mind all Deseret Mutual plans are
preferred provider organizations or PPOs. This means to receive
your maximum benefits—and lower your out-of-pocket costs—you
must receive services from providers contracted for your specific
plan.
For 2016, your employer has made Deseret Premier available for the
first time in Utah and Southeastern Idaho. This high-option national
plan, replacing Deseret Choice, is more portable and goes almost
anywhere you do. A modest out-of-network deductible applies, but if you
do need to see an out-of-network provider, Deseret Premier still pays
80% after you’ve met the plan deductible.
UTID
With this and a few other changes described below, choosing a medical
plan can be a little daunting. To help you navigate this unfamiliar
landscape, we’ve created simple summaries of the employer-sponsored
plans available to you. You also have available to you a Notice of Change
that specifically details all changes for 2016. Be sure to review that notice
as well as this medical plan comparison to make the most informed
choices for you and your family.
If you are currently a Deseret Choice participant you must select
another plan that best meets your needs. If you do not act, your 2016
plan will be Deseret Premier.
DESERET PREMIER
Generally, Deseret Premier covers primary care—like office visits—at
100% after your $15 copayment to a contracted primary care physician
or your $25 copayment to a contracted specialist. Most other services are
covered at 90%; you’re responsible for the remaining 10%.
When you receive services from Deseret Premier contracted
providers, certain preventive services will be covered at 100%, such
as colonoscopies, mammograms, physical exams, and well-child
care. Limitations do apply; see the preventive services section of your
handbook for details.
To be eligible for benefits, you or your physician must preauthorize some
services with Deseret Mutual, such as surgery and home healthcare.
For some services, such as surgery and physical therapy, you must satisfy
an annual deductible if you receive care from non-contracted providers
($300 per person or $600 per family).
DESERET SELECT
Generally, Deseret Select includes hospitals and doctors affiliated with
Intermountain Healthcare. Deseret Select covers primary care—such as
office visits—at 100% after your $15 copayment to a contracted physician
or your $25 copayment to a contracted specialist. Most other services are
covered at 90%; you’re responsible for the remaining 10%.
When you receive services from Deseret Select contracted providers,
certain preventive services will be covered at 100%, such as
mammograms, colonoscopies, and well-child care. Limitations do apply;
see the preventive services section of your handbook for details.
New for 2016, Deseret Select will cover services from non-contracted
providers at 60%. You’re responsible for the remaining 40%.
To be eligible for benefits, you or your physician must preauthorize some
services with Deseret Mutual, such as surgery and home healthcare.
DESERET VALUE
Generally, Deseret Value covers primary care—such as office visits—at
100% after your $15 copayment to a contracted primary care physician
or your $25 copayment to a contracted specialist. Most other services are
covered at 70%; you’re responsible for the remaining 30%.
When you receive services from Deseret Value contracted providers,
certain preventive services are covered at 100%, such as colonoscopies,
mammograms, physical exams, and well-child care. Limitations do apply;
see the preventive services section of your handbook for details.
To be eligible for benefits, you or your physician must preauthorize some
services with Deseret Mutual, such as surgery and home healthcare.
For some services, such as surgery and physical therapy, you must satisfy
an annual deductible if you receive care from non-contracted providers
($300 per person or $600 per family).
DESERET PROTECT
Deseret Protect has an annual deductible that applies to all major medical
expenses, such as surgeries and inpatient hospitalizations ($1,000 per
person or $2,000 per family for services from contracted Deseret Protect
providers; $1,300 per person or $2,600 per family for non-contracted
providers).
Generally, Deseret Protect covers primary medical care—such as office
visits—at 100% after your $15 copayment to a contracted primary care
physician or your $30 copayment to a contracted specialist. The plan
covers most other medical services after your deductible at 70%. You’re
responsible for the remaining 30%.
To be eligible for benefits, you or your physician must preauthorize some
services with Deseret Mutual, such as surgery and home healthcare.
When you receive services from Deseret Protect contracted providers,
certain preventive services are covered at 100%, such as colonoscopies,
mammograms, physical exams, and well-child care. Limitations do apply;
see the preventive services section of your handbook for details.
Deseret Protect prescription coverage is limited primarily to generic
medications.
Due to Deseret Protect’s low premiums, some services are not covered.
These include acupuncture, allergy testing and injections, eye exams,
high-cost injections, lifestyle screenings, and obesity surgery. Also,
Deseret Protect has a narrower prescription drug formulary. This means
many of the medications covered by other Deseret Mutual plans may not
be covered by Deseret Protect.
THINGS TO REMEMBER
All Deseret Premier, Deseret Value, Deseret Protect, and Deseret Select
benefits are subject to the maximum allowable limits determined by Deseret
Mutual.
Receiving care from contracted providers for your specific Deseret Mutual plan
protects you financially.
Contracted providers accept what you pay (your copayments and
coinsurance) and what Deseret Mutual pays as payment in full for
eligible services. They won’t bill you for amounts exceeding the
maximum allowable limits.
For example, if your physician charges $100 for an office visit but the
Deseret Mutual maximum allowable amount is $80, he or she won’t bill
you for the remaining $20. When you receive care from non-contracted
providers, those providers can bill you for the difference. For information
about Deseret Mutual contracted providers in your area, visit www.
dmba.com.
Deseret Mutual offers the most comprehensive access to contracted hospitals
of any health plan organization along the Wasatch Front.
This includes multiple hospital networks such as Intermountain
Healthcare (Intermountain Medical Center), the University of Utah
(University Hospital), Iasis (Salt Lake Regional and Jordan Valley
hospitals), and MountainStar (St. Mark’s and Ogden Regional hospitals).
Remember, the provider networks vary from plan to plan. In choosing
your coverage, make sure to check providers who are contracted for your
specific plan. Visit our website at www.dmba.com for information about
contracted providers in your area.
We’re contracted nationally with UnitedHealthcare’s Options PPO network to
provide you coverage when you’re out of your service area.
If you travel out of the Deseret Mutual service area and need medical
care, you can take advantage of UnitedHealthcare’s discounts and be
protected from paying charges that exceed our maximum allowable
limits.
At Deseret Mutual, we’ve decided to maintain the benefit structure that was
in place at the time the Patient Protection and Affordable Care Act passed. So
Deseret Mutual health plans are considered “grandfathered” under the law.
As a grandfathered plan, your coverage may not include certain
consumer protections included in the law that apply to other plans. For
example, healthcare reform says all preventive health services must be
covered at no cost to you, the employee.
Grandfathered plans must comply with other consumer protections
included in the Affordable Care Act—like eliminating lifetime limits on
essential benefits, which Deseret Mutual has already done.
For questions about which protections apply and do not apply, as well as
information about what could cause a plan to change from grandfathered
to non-grandfathered status, please contact us.
Or you’re welcome to contact the Employee Benefits Security
Administration, U.S. Department of Labor, at 866-444-3272 or www.dol.
gov/ebsa/healthreform.
FOR MORE INFORMATION
Remember, this comparison only points out highlights and important
differences you should consider when choosing your coverage. Go to
www.dmba.com for more detailed information about Deseret Mutual’s
health plans.
If you have questions about this information, please call:
Deseret Mutual
Salt Lake City area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-578-5600
Toll free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-777-3622
We have made every effort to accurately describe the benefits and ensure that information given to you is
consistent with other benefit-related communications. However, if there is any discrepancy or conflict between
information in this document and other plan materials, the terms outlined in the Legal Plan Document will
govern. You can view the Summary Plan Description (benefits handbook) by logging into www.dmba.com.
DESERET PREMIER à
SUMMARY OF BENEFITS
AVAILABLE HOSPITALS IN PLAN
Juab
Salt Lake
Sanpete
Summit
Tooele
Utah
Wasatch
Weber
Bannock
Bear Lake
Bingham
UTAH
Bear River Valley Hospital
Brigham City Community Hospital
Davis Hospital & Medical Center
Lakeview Hospital
Central Valley Medical Center
Alta View Hospital
Intermountain Medical Center
Orthopedic Specialty Hospital
LDS Hospital
Lone Peak Hospital
Riverton Hospital
Primary Children’s Medical Center
Huntsman Cancer Hospital
Jordan Valley Hospital
Pioneer Valley Hospital
Salt Lake Regional Medical Center
St. Mark’s Hospital
University Hospital
Gunnison Valley Hospital
Sanpete Valley Hospital
Park City Medical Center
Mountain West Medical Center
American Fork Hospital
Orem Community Hospital
Utah Valley Regional Medical Ctr.
Mountain Point Medical Center
Mountain View Hospital
Timpanogos Regional Hospital
Heber Valley Medical Center
McKay-Dee Hospital
Ogden Regional Medical Center
IDAHO
Portneuf Medical Center
Bear Lake Memorial Hospital
Bingham Memorial Hospital
Idaho Doctors' Hospital
Bonneville Eastern Idaho Regional Medical Center
Mountain View Hospital
Caribou
Caribou Memorial Hospital
Cassia
Cassia Regional Medical Center
Franklin
Franklin County Medical Center
Madison
Madison Memorial Hospital
Oneida
Oneida County Hospital
Power
Harms Memorial
Teton
Teton Valley Hospital
* Preauthorization may be required for these services. If you do not
preauthorize with Deseret Mutual, you must pay up to the first $200
per service.
Annual deductible does not apply
Davis
Physician Services:
Office Visits
Physician Services:
Routine Adult Physicals
Well-Child Care
Well-Woman Care
Routine Eye Exams
Outpatient Mental Health
Therapy
Outpatient Laboratory
WHAT YOU PAY
Deseret Premier PCP: $15 per visit
Deseret Premier specialist: $25 per visit
Non-Deseret Premier PCP: $20 per visit
Non-Deseret Premier specialist: $30 per visit
Deseret Premier PCP: Nothing
Deseret Premier specialist: Nothing
Non-Deseret Premier PCP: $20 per visit
Non-Deseret Premier specialist: $30 per visit
Routine physical and well-woman exams are eligible once
per calendar year. No limits on well-child care.
Deseret Premier provider: $25 per visit
Non-Deseret Premier provider: $30 per visit
One exam is covered every calendar year
Deseret Premier provider: $15 for individual and group
therapy. Non-Deseret Premier provider: $20 for individual
and group therapy.
Nothing (the plan pays 100%)
Prescription Drugs
Retail formulary drugs: 30% for 30-day supply
Mail-order formulary drugs: 25% for 90-day supply; up to
$85 per prescription
All non-formulary drugs: 100% (not covered)
Basic Radiology
Deseret Premier provider: 10%
Non-Deseret Premier provider: 20%
Hospital
Emergency Room
Annual deductible applies
Box Elder
SERVICES
$75 per visit plus 10%
Inpatient Hospital
Services*
Deseret Premier provider: 10%
Non-Deseret Premier provider: 20%
Inpatient Maternity
Services
Deseret Premier provider: 10%
Non-Deseret Premier provider: 20%
Inpatient Mental Health
Services*
Deseret Premier provider: 10%
Non-Deseret Premier provider: 20%
Major Radiology
Services*
Deseret Premier provider: 10%
Non-Deseret Premier provider: 20%
Maternity (Physician)
Deseret Premier provider: 10%
Non-Deseret Premier provider: 20%
Surgery*
Physical Therapy
Deseret Premier provider: 10%
Non-Deseret Premier provider: 20%
Deseret Premier provider: $25 per visit
Non-Deseret Premier provider: $30 per visit
Up to 25 visits per calendar year
Chiropractic Therapy
Deseret Premier provider: $25 per visit
Non-Deseret Premier provider: $30 per visit
Up to 25 visits per calendar year
Medical Equipment*
Deseret Premier provider: 10%
Non-Deseret Premier provider: 20%
Annual Deductible
Your Annual Maximum
Out-of-Pocket Cost
$300 per person or $600 per family for services from nonnetwork providers. You are responsible for over-maximum
allowable amounts when using non-contracted providers.
$2,000 per person or $4,000 per family. Then the plan pays
100% of eligible charges. The annual deductible does
not apply. Copayments still apply after the out-of-pocket
maximum is met.
DESERET SELECT à
AVAILABLE HOSPITALS IN PLAN
Box Elder
Davis
Juab
Salt Lake
Sanpete
Summit
Tooele
Utah
Wasatch
Weber
Bannock
Bear Lake
Bingham
UTAH
Bear River Valley Hospital
...
Davis Hospital & Medical Center
...
Central Valley Medical Center
Alta View Hospital
Intermountain Medical Center
Orthopedic Specialty Hospital
LDS Hospital
...
Riverton Hospital
Primary Children’s Medical Center
...
...
...
...
...
...
Gunnison Valley Hospital
Sanpete Valley Hospital
Park City Medical Center
Mountain West Medical Center
American Fork Hospital
Orem Community Hospital
Utah Valley Regional Medical Ctr.
...
...
...
Heber Valley Medical Center
McKay-Dee Hospital
...
IDAHO
Portneuf Medical Center
Bear Lake Memorial Hospital
Bingham Memorial Hospital
Idaho Doctors' Hospital
Bonneville Eastern Idaho Regional Medical Center
...
Caribou
Caribou Memorial Hospital
Cassia
Cassia Regional Medical Center
Franklin
Franklin County Medical Center
Madison
Oneida
Power
Teton
Madison Memorial Hospital
Oneida County Hospital
Harms Memorial
Teton Valley Hospital
* Preauthorization may be required for these services. If you do not
preauthorize with Deseret Mutual, you must pay up to the first $200
per service. Non-contracted providers can charge over maximum
allowable limits. You are responsible for over-maximum allowable
amounts when using non-contracted providers.
SUMMARY OF BENEFITS
SERVICES
Physician Services:
Office Visits
Physician Services:
Routine Adult Physicals
Well-Child Care
Well-Woman Care
WHAT YOU PAY
Deseret Select PCP: $15 per visit
Deseret Select specialist: $25 per visit
Non-Deseret Select PCP: $25 per visit
Non-Deseret Select Specialist: $35 per visit
Deseret Select PCP: Nothing
Deseret Select specialist: Nothing
Non-Deseret Select PCP: $25
Non-Deseret Select Specialist: $35
Routine physical and well-woman exams are eligible
once per calendar year. No limits on well-child care.
Routine Eye Exams
Deseret Select provider: $25 per visit
Non-Deseret Select provider: $35
One exam is covered every calendar year
Outpatient Mental Health Deseret Select provider: $15 for individual and group
Therapy
therapy
Non-Deseret Select provider: $25
Outpatient Laboratory
Nothing (the plan pays 100%)
Prescription Drugs
Retail formulary drugs: 30% for 30-day supply
Mail-order formulary drugs: 25% for 90-day supply; up
to $85 per prescription
All non-formulary drugs: 100% (not covered)
Basic Radiology
Deseret Select provider: 10%
Non-Deseret Select provider: 40%
Hospital
Emergency Room
$75 per visit plus 10%
Inpatient Hospital
Services*
Deseret Select provider: 10%
Non-Deseret Select provider: 40%
Inpatient Maternity
Services
Deseret Select provider: 10%
Non-Deseret Select provider: 40%
Inpatient Mental Health
Services*
Deseret Select provider: 10%
Non-Deseret Select provider: 40%
Major Radiology
Services*
Deseret Select provider: 10%
Non-Deseret Select provider: 40%
Surgery*
Deseret Select provider: 10%
Non-Deseret Select provider: 40%
Maternity (Physician)
Deseret Select provider: 10%
Non-Deseret Select provider: 40%
Physical Therapy
Deseret Select provider: $25 per visit
Non-Deseret Select provider: $35 per visit
Up to 25 visits per calendar year
Chiropractic Therapy
CHP provider: $25 per visit; no visit limit when
preauthorized and medically necessary
Non-CHP provider: $35 per visit; up to five visits per year
Medical Equipment*
Deseret Select provider: 10%
Non-Deseret Select provider: 40%
$2,000 per person or $4,000 per family for services from
Deseret Select providers. $4,000 per person or $8,000
per family for non-Deseret Select providers. Then the
plan pays 100% of eligible charges. Copayments still
apply after the out-of-pocket maximum is met. The
annual deductible does not apply.
Your Annual Maximum
Out-of-Pocket Cost
DESERET VALUE à
SUMMARY OF BENEFITS
AVAILABLE HOSPITALS IN PLAN
Juab
Salt Lake
Sanpete
Summit
Tooele
Utah
Wasatch
Weber
Bannock
Bear Lake
Bingham
UTAH
Bear River Valley Hospital
Brigham City Community Hospital
Davis Hospital & Medical Center
Lakeview Hospital
Central Valley Medical Center
Alta View Hospital
Intermountain Medical Center
Orthopedic Specialty Hospital
LDS Hospital
Lone Peak Hospital
Riverton Hospital
Primary Children’s Medical Center
Huntsman Cancer Hospital
Jordan Valley Hospital
Pioneer Valley Hospital
Salt Lake Regional Medical Center
St. Mark’s Hospital
University Hospital
Gunnison Valley Hospital
Sanpete Valley Hospital
Park City Medical Center
Mountain West Medical Center
American Fork Hospital
Orem Community Hospital
Utah Valley Regional Medical Ctr.
Mountain Point Medical Center
Mountain View Hospital
Timpanogos Regional Hospital
Heber Valley Medical Center
McKay-Dee Hospital
Ogden Regional Medical Center
IDAHO
Portneuf Medical Center
Bear Lake Memorial Hospital
Bingham Memorial Hospital
Idaho Doctors' Hospital
Bonneville Eastern Idaho Regional Medical Center
Mountain View Hospital
Caribou
Caribou Memorial Hospital
Cassia
Cassia Regional Medical Center
Franklin
Franklin County Medical Center
Madison
Madison Memorial Hospital
Oneida
Oneida County Hospital
Power
Harms Memorial
Teton
Teton Valley Hospital
* Preauthorization may be required for these services. If you do not
preauthorize with Deseret Mutual, you must pay up to the first $200
per service.
Annual deductible does not apply
Davis
Physician Services:
Office Visits
Physician Services:
Routine Adult Physicals
Well-Child Care
Well-Woman Care
Routine Eye Exams
Outpatient Mental Health
Therapy
Outpatient Laboratory
WHAT YOU PAY
Deseret Value PCP: $15 per visit
Deseret Value specialist: $25 per visit
Non-Deseret Value PCP: $20 per visit
Non-Deseret Value specialist: $30 per visit
Deseret Value PCP: Nothing
Deseret Value specialist: Nothing
Non-Deseret Value PCP: $20 per visit
Non-Deseret Value specialist: $30 per visit
Routine physical and well-woman exams are eligible once
per calendar year. No limits on well-child care.
Deseret Value provider: $25 per visit
Non-Deseret Value provider: $30 per visit
One exam is covered every calendar year
Deseret Value provider: $15 for individual and group therapy.
Non-Deseret Value provider: $20 for individual and group
therapy
Nothing (the plan pays 100%)
Prescription Drugs
Retail formulary drugs: 50% for 30-day supply.
Mail-order formulary drugs: 45% for 90-day supply; up to
$140 per prescription
All non-formulary drugs: 100% (not covered)
Basic Radiology
Deseret Value provider: 30%
Non-Deseret Value provider: 40%
Hospital
Emergency Room
Annual deductible applies
Box Elder
SERVICES
$75 per visit plus 30%
Inpatient Hospital
Services*
Deseret Value provider: 30%
Non-Deseret Value provider: 40%
Inpatient Maternity
Services
Deseret Value provider: 30%
Non-Deseret Value provider: 40%
Inpatient Mental Health
Services*
Deseret Value provider: 30%
Non-Deseret Value provider: 40%
Major Radiology
Services*
Deseret Value provider: 30%
Non-Deseret Value provider: 40%
Maternity (Physician)
Deseret Value provider: 30%
Non-Deseret Value provider: 40%
Surgery*
Physical Therapy
Deseret Value provider: 30%
Non-Deseret Value provider: 40%
Deseret Value provider: $25 per visit
Non-Deseret Value provider: $30 per visit
Up to 25 visits per calendar year
Chiropractic Therapy
Deseret Value provider: $25 per visit
Non-Deseret Value provider: $30 per visit
Up to 25 visits per calendar year
Medical Equipment*
Deseret Value provider: 30%
Non-Deseret Value provider: 40%
Annual Deductible
$300 person or $600 per family for services from nonnetwork providers. You are responsible for over-maximum
allowable amounts when using non-contracted providers.
Your Annual Maximum
Out-of-Pocket Cost
$4,000 per person or $6,000 per family. Then the plan pays
100% of eligible charges. The annual deductible does
not apply. Copayments still apply after the out-of-pocket
maximum is met.
DESERET PROTECT à
SUMMARY OF BENEFITS
AVAILABLE HOSPITALS IN PLAN
Juab
Salt Lake
Sanpete
Summit
Tooele
Utah
Wasatch
Weber
Bannock
Bear Lake
Bingham
UTAH
Bear River Valley Hospital
Brigham City Community Hospital
Davis Hospital & Medical Center
Lakeview Hospital
Central Valley Medical Center
Alta View Hospital
Intermountain Medical Center
Orthopedic Specialty Hospital
LDS Hospital
Lone Peak Hospital
Riverton Hospital
Primary Children’s Medical Center
Huntsman Cancer Hospital
Jordan Valley Hospital
Pioneer Valley Hospital
Salt Lake Regional Medical Center
St. Mark’s Hospital
University Hospital
Gunnison Valley Hospital
Sanpete Valley Hospital
Park City Medical Center
Mountain West Medical Center
American Fork Hospital
Orem Community Hospital
Utah Valley Regional Medical Ctr.
Mountain Point Medical Center
Mountain View Hospital
Timpanogos Regional Hospital
Heber Valley Medical Center
McKay-Dee Hospital
Ogden Regional Medical Center
IDAHO
Portneuf Medical Center
Bear Lake Memorial Hospital
Bingham Memorial Hospital
Idaho Doctors' Hospital
Bonneville Eastern Idaho Regional Medical Center
Mountain View Hospital
Caribou
Caribou Memorial Hospital
Cassia
Cassia Regional Medical Center
Franklin
Franklin County Medical Center
Madison
Oneida
Power
Teton
Madison Memorial Hospital
Oneida County Hospital
Harms Memorial
Teton Valley Hospital
* Preauthorization may be required for these services. If you do not
preauthorize with Deseret Mutual, you must pay up to the first $200
per service.
** Copayments DO NOT apply toward the annual deductible.
Annual deductible does not apply
Davis
Physician Services:
Office Visits
Annual deductible applies **
Box Elder
SERVICES
Physician Services:
Routine Adult Physicals
Well-Child Care
Well-Woman Care
Routine Eye Exams
WHAT YOU PAY
Deseret Protect PCP: $15 per visit
Deseret Protect specialist: $30 per visit
Non-Deseret Protect PCP: $20 per visit
Non-Deseret Protect specialist: $35 per visit
Deseret Protect PCP: Nothing
Deseret Protect specialist: Nothing
Non-Deseret Protect PCP: $20 per visit
Non-Deseret Protect specialist: $35 per visit
Routine physical and well-woman exams are eligible
once per calendar year. No limits on well-child care.
100% (not covered)
Outpatient Mental Health Deseret Protect provider: $15 for individual and group
Therapy
therapy
Non-Deseret Protect provider: $20 for individual and
group therapy
Outpatient Laboratory
Nothing (the plan pays 100%)
Prescription Drugs
Generic drugs: 20% for retail and mail-service
(limited list of generic drugs)
Brand-name drugs: 50% for retail and mail service
(very limited list of brand-name drugs)
Basic Radiology
Deseret Protect provider: 30%
Non-Deseret Protect provider: 40%
Hospital
Emergency Room
$75 per visit plus 30%
Inpatient Hospital
Services*
Deseret Protect provider: 30%
Non-Deseret Protect provider: 40%
Inpatient Maternity
Services
Deseret Protect provider: 30%
Non-Deseret Protect provider: 40%
Inpatient Mental Health
Services*
Deseret Protect provider: 30%
Non-Deseret Protect provider: 40%
Major Radiology
Services*
Deseret Protect provider: 30%
Non-Deseret Protect provider: 40%
Surgery*
Deseret Protect provider: 30%
Non-Deseret Protect provider: 40%
Maternity (Physician)
Deseret Protect provider: 30%
Non-Deseret Protect provider: 40%
Physical Therapy
Deseret Protect provider: $30 per visit
Non-Deseret Protect provider: $35 per visit
Up to 15 visits per calendar year
Chiropractic Therapy
Deseret Protect provider: $30 per visit
Non-Deseret Protect provider: $35 per visit
Up to 15 visits per calendar year
Medical Equipment*
All providers 50%
Annual Deductible
Your Annual Maximum
Out-of-Pocket Cost
$1,000/person, $2,000/family for network providers;
$1,300/person, $2,600/family for non-network. You
are responsible for over-maximum allowable amounts
when using non-contracted providers.
$4,000 per person or $6,000 per family. Then the plan
pays 100% of eligible charges. The annual deductible
does not apply. Copayments still apply after the out-ofpocket maximum is met.
NOTES: