Information about your insurance and the coverage it gives
| EMIA Pool September 01, 2022 - August 31, 2023 |
Care Plus | |
| PHD3500 QHDHP | Participating. Provider Option | Non-Participating Provider Option |
| Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) | ♦20% | ♦40% |
| Skilled Nursing Facility (30 days per Year) (Admission must be within 5 days of discharge from Hospital Confinement) |
♦20% | ♦40% |
| Medical/Surgical Care (Outpatient) | ♦20% | ♦40% |
| Emergency Room (ER) | ♦20% | ♦20% |
| Major Diagnostic Test, CT Scan, MRI, NMR (Outpatient) | ♦20% | ♦40% |
| Minor Diagnostic Test, X-ray, Lab (Inpatient) | ♦20% | ♦40% |
| Minor Diagnostic Test, X-ray, Lab (Outpatient) | ♦20% | ♦40% |
| Newborn | ♦20% | ♦40% |
| InstaCare/Urgent Care Clinic | ♦20% | ♦40% |
| Eligible Preventive Services | Covered 100% | Not Covered |
| REHABILITATION THERAPY BENEFIT | YOU PAY | |
| Inpatient – physical, speech, occupational, cardiac, or pulmonary (40 days per person per Year) |
♦20% | ♦40% |
| ACCIDENT AND LIFE THREATENING CONDITION | YOU PAY | |
| Medical/Surgical – Physician/Facility/ER | Covered as any other condition | Covered as a Participating Benefit to the Maximum Allowable Charge |
| Ambulance Land/Air (Accident & Life-threatening) | ♦20% | |
| Orthodontic Injury Treatment | ♦20% | |
| Dental Injury Treatment | ♦20% | |
| TRANSPLANT BENEFIT | YOU PAY | |
| Heart, Liver, Pancreas, Bone Marrow, Cornea, Lung, Kidney | Covered as any other condition | Not Covered |
| MEDICAL SUPPLIES & EQUIPMENT | YOU PAY | |
| Diabetic Testing Supplies (90 day supply) | ♦30% | ♦40% |
| Medical Supplies | ♦20% | ♦40% |
| Medical Supplies (office) | ♦20% | ♦40% |
| Durable Medical Equipment/Prosthetics/Orthotic Devices | ♦20% | ♦40% |
| Orthotic Supplies (foot inserts & arch supports) | Not Covered | Not Covered |
| Growth Hormone | Not Covered | Not Covered |
| MENTAL HEALTH & DRUG/ALCOHOL TREATMENT | YOU PAY | |
| Inpatient Facility | ♦20% | ♦40% |
| Inpatient Physician Visits | ♦20% | ♦40% |
| Residential Treatment (30 days per year) | ♦20% | ♦40% |
| Outpatient Facility | ♦20% | ♦40% |
| Physician Office Visits Psychologist / LCSW / APRN / Psychiatrist |
♦20% | ♦40% |
| ADDITIONAL BENEFITS | YOU PAY | |
| Adoption Indemnity Benefit | The Plan pays a maximum of $4,000 towards adoption expenses. | |
| TMJ Syndrome Non Surgical Treatment | 20% | Not Covered |
| Orthognathic/Mandibular Osteotomy | 20% | Not Covered |
| Total Parenteral Nutrition (TPN) | ♦20% | Not Covered |
| Initial assessment and diagnosis of Primary Infertility | 20% | Not Covered |
| Reduction Mammoplasty | ♦20% | Not Covered |
| Autism Applied Behavior Analysis | ♦20% | ♦40% |
| Services designated ♦ are subject to first dollar Medical Deductible | ||
| Services designated *, premiums, balance-billed charges, charges for services this Plan doesn’t cover, amounts in excess of benefit limits, and penalties for failure to obtain Preauthorization, do not accumulate toward your Out-of-pocket Maximum. | ||
| PROVIDER NETWORK | ||
| Utah | EMI Health Care Plus | |
| Outside of Utah | Cigna PPO | |
| PLEASE NOTE: This is a summary only and does not guarantee benefits. All benefits are subject to the terms, limitations, and exclusions set forth in the Plan document and in the Summary Plan Description (SPD)/handbook of the Plan. Any discrepancies between this summary, the SPD/handbook, and the Plan document are resolved in favor of the Plan document. For more information, including Preauthorization, refer to the SPD/ handbook or the Plan document, or contact EMI Health Customer Service Department. | ||
| Administered by Educators Mutual Insurance Association | ||
| EMI Health Customer Service 801-262-7475 or 1-800-662-5851 | ||
| Self Funded Employee Medical Benefit Plan | ||
| All services are subject to the EMI Health Maximum Allowable Charge. When using a Non-participating Provider, the Covered Person is | ||
| responsible for all fees in excess of the Maximum Allowable Charge. | ||
| EMIA Pool | Care Plus | |
| September 01, 2022 - August 31, 2023 PHD5000 QHDHP | Participating Provider Option | Non-Participating Provider Option |
| GENERAL INFORMATION | YOU PAY | |
| Benefit Accumulator | Contract Year | |
| Dependent Age Limit | 26 | |
| Out-of-Pocket Maximum (Per Person/Family Per Year) | $5,000 / $10,000 | $6,000 / $12,000 |
| Medical Deductible (Per Person/Family Per Year). Please note ♦ | $5,000 / $10,000 | $5,000 / $10,000 |
| Non-Preauthorization Patient Penalty | Not Applicable | 50% Reduction in Benefits |
| Non-Preauthorization Provider Sanction | 50% Reduction in Payment | Not Applicable |
| PRESCRIPTION DRUG BENEFITS (If brand is purchased when generic is available, member pays the copay plus the difference between the generic and the brand price) |
YOU PAY | |
| Participating Pharmacy (30 day supply) | ♦Generic - 10% | |
| ♦Preferred - 30% | ||
| ♦Non-Preferred - 50% | ||
| Non-Participating Pharmacy | Not Covered | |
| Mail Order (90 day supply) | ♦Generic - 10% | |
| ♦Preferred - 30% | ||
| ♦Non-Preferred - 50% | ||
| PREVENTIVE SERVICES | YOU PAY | |
| Routine Physical Exam (1 visit per Year) | Covered 100% | Not Covered |
| Routine Gynecological Exam (1 visit per Year) | Covered 100% | Not Covered |
| Family History Exam (1 visit per Year) | Covered 100% | Not Covered |
| Routine Pap Smear & Mammogram (1 per Year) | Covered 100% | Not Covered |
| Routine Well-Baby Exams | Covered 100% | Not Covered |
| Covered Immunizations | Covered 100% | Not Covered |
| Routine Vision Exam (1 visit per Year) | Covered 100% | Not Covered |
| Routine Hearing Exam (1 visit per Year) | Covered 100% | Not Covered |
| PHYSICIAN & PROFESSIONAL SERVICES | YOU PAY | |
| Physician Office Visits (primary care) | ♦20% | ♦40% |
| Physician Office Visits (secondary care) | ♦20% | ♦40% |
| Physician Office Visits (after hours) | ♦20% | ♦40% |
| Physician Visits (Inpatient) | ♦20% | ♦40% |
| Physician Visits (Outpatient) | ♦20% | ♦40% |
| Major Diagnostic Test, CT Scan, MRI, NMR (office) | ♦20% | ♦40% |
| Minor Diagnostic Test, Radiology, Lab (office) | ♦20% | ♦40% |
| Minor Diagnostic Test, Radiology, Lab (Inpatient) | ♦20% | ♦40% |
| Minor Diagnostic Test, Radiology, Lab (Outpatient) | ♦20% | ♦40% |
| Injections (office) | ♦20% | ♦40% |
| Surgery (office) | ♦20% | ♦40% |
| Surgery (Inpatient) | ♦20% | ♦40% |
| Surgery (Outpatient) | ♦20% | ♦40% |
| Anesthesiology (office) | ♦20% | ♦40% |
| Anesthesiology (Inpatient) | ♦20% | ♦40% |
| Anesthesiology (Outpatient) | ♦20% | ♦40% |
| Routine Prenatal & Delivery (Dependent maternity included) | ♦20% | ♦40% |
| Home Health and Hospice Care (in lieu of Hospital) (for supplies, see Medical Supplies and Equipment) | ♦20% | ♦40% |
| Rehabilitation Therapy (Outpatient physical, speech, occupational, cardiac, or pulmonary - 20 visits per Year) |
♦20% | ♦40% |
| Chiropractic Therapy (20 visits per Year) | ♦20% | ♦40% |
| Allergy Testing | ♦20% | ♦40% |
| Allergy Treatment/Serum | ♦20% | ♦40% |
| HOSPITAL/FACILITY BENEFITS | YOU PAY | |
| (Physician & Professional Services are not included in this section.) | ||
| Medical/Surgical/Maternity/Intensive Care (semi-private room) | ♦20% | ♦40% |
PHD3500_Coverage.pdf