Henriksen Butler / Medical

What comes out of my pay?How much will I pay out of my own pocket?What will I pay after I meet my deductible?Will my doctor be in-network?

Network Options: Preferred ValueCare or FocalPoint
You’ve built a trusting relationship and you want to keep it. But, did you know that you can also save money by using an in-network provider? That’s why you will be able to choose a provider network that is right for you and your family’s health and wellbeing.

Utah: (888) 675-6570 | Outside Utah: (800) 810-2583 | regence.com | Group #60022180

Medical Plans

Regence - Traditional $500 PPO Plan
With this Traditional $500 PPO Plan you will only have access to the Preferred ValueCare (PVC) Network. An important thing to know about this plan is that both the family deductible and family out-of-pocket maximum are embedded. This means that on a family plan each covered member must meet their individual deductible — up to the maximum family deductible — and each covered member has an individual out-of-pocket maximum — up to the family out-of-pocket maximum.

Please check with Regence to see if your provider is in the Preferred ValueCare (PVC) Network so that you can take advantage of greater discounts on care for you and your family.
 
 
TRADITIONAL $500 PPO PLAN
PREFERRED VALUECARE (PVC) NETWORK
 
In-Network
Out-of-Network*
Annual Deductible
Embedded
January 1 — December 31
You pay up to
$500 per individual
$500 per member / $1,000 per family
You pay up to
$1,000 per individual
$1,000 per member / $2,000 per family
Coinsurance
You pay 20% AD
You pay 40% AD
Out-of-pocket Maximum
Embedded
January 1 — December 31
No more than
$3,000 per individual
$3,000 per member / $6,000 per family
No more than
$6,000 per individual
$6,000 per member / $12,000 per family
Preventive Services
You pay
$0 according to government guidelines
You pay
40% AD
Office Visits
Primary Care
Specialist
Chiropractic (10 visits/year)
MDLive Telemedicine
Virtual Care Telehealth **
You pay
$25 copay
$45 copay
20% AD
$10 copay
$25 copay
You pay
40% AD
40% AD
40% AD
Not Covered
40% AD
Mental Health Services
Office Visit
Inpatient
You pay
$25 copay
20% AD
You pay
40% AD
40% AD
Emergency Services
Urgent Care
Emergency Room
You pay
$25 copay
$150 copay then 20% AD
You pay
40% AD
Covered as In-Network
Inpatient & Outpatient
Inpatient Hospital
Outpatient Surgery
You pay
20% AD
20% AD
You pay
40% AD
40% AD
Prescription Medication
Generic / Preferred / Brand
Retail (30-day supply)
Mail Order (90-day supply)
You pay $10 / 35% / 50%
You pay $25 / 30% / 50% retail
Health Care Account
Flexible Spending Account (FSA)
AD: After Deductible
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
** Virtual Care Telehealth visits available and will not be subject to deductible through Dececember 2022

This information is designed to help you choose a benefit plan for 2022 only. Please refer to the Plan Documents provided by the carrier for information regarding coverage, limitations and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.
Regence - Traditional $2,000 PPO Plan
With this Traditional $2,000 PPO Plan you will have access to the Preferred ValueCare (PVC) Network or the FocalPoint Network. An important thing to know about this plan is that both the family deductible and family out-of-pocket maximum are embedded. This means that on a family plan each covered member must meet their individual deductible — up to the maximum family deductible — and each covered member has an individual out-of-pocket maximum — up to the family out-of-pocket maximum.

Please check with Regence to see if your provider is in your chosen network so that you can take advantage of greater discounts on care for you and your family.
 
 
TRADITIONAL $2,000 PPO PLAN
PREFERRED VALUECARE (PVC) NETWORK
OR FOCALPOINT NETWORK
 
In-Network
Out-of-Network*
Annual Deductible
Embedded
January 1 — December 31
You pay up to
$2,000 per individual
$2,000 per member / $4,000 per family
You pay up to
$4,000 per individual
$4,000 per member / $8,000 per family
Coinsurance
You pay 20% AD
You pay 40% AD
Out-of-pocket Maximum
Embedded
January 1 — December 31
No more than
$4,500 per individual
$4,500 per member / $9,000 per family
No more than
$9,000 per individual
$9,000 per member / $18,000 per family
Preventive Services
You pay
$0 according to government guidelines
You pay
40% AD
Office Visits
Primary Care
Specialist
Chiropractic (10 visits/year)
MDLive Telemedicine
Virtual Care Telehealth **
You pay
$25 copay
$45 copay
20% AD
$10 copay
$25 copay
You pay
40% AD
40% AD
40% AD
Not Covered
40% AD
Mental Health Services
Office Visit
Inpatient
You pay
$25 copay
20% AD
You pay
40% AD
40% AD
Emergency Services
Urgent Care
Emergency Room
You pay
$25 copay
$150 copay then 20% AD
You pay
40% AD
Covered as In-Network
Inpatient & Outpatient
Inpatient Hospital
Outpatient Surgery
You pay
20% AD
20% AD
You pay
40% AD
40% AD
Prescription Medication
Generic / Preferred / Brand
Retail (30-day supply)
Mail Order (90-day supply)
You pay $10 / 35% / 50%
You pay $25 / 30% / 50% retail
Health Care Account
Flexible Spending Account (FSA)
Health Care Reimbursement Account (HRA)
AD: After Deductible
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
** Virtual Care Telehealth visits available and will not be subject to deductible through Dececember 2022

This information is designed to help you choose a benefit plan for 2022 only. Please refer to the Plan Documents provided by the carrier for information regarding coverage, limitations and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.
Regence - HDHP $2,500 - High Deductible Health Plan
With this HDHP $2,500 - High Deductible Health Plan you you will have access to the Preferred ValueCare (PVC) Network or the FocalPoint Network. An important thing to know about this plan is that both the family deductible and family out-of-pocket maximum are non-embedded. With a non-embedded deductible, there is only a family deductible and a family out-of-pocket maximum. All family members’ expenses count toward the family deductible until it is met, and then they are all covered with the health plan’s usual copays or coinsurance.

Please check with Regence to see if your provider is in your chosen network so that you can take advantage of greater discounts on care for you and your family.
 
 
HDHP $2,500 HIGH DEDUCTIBLE HEALTH PLAN
PREFERRED VALUECARE (PVC) NETWORK
OR FOCALPOINT NETWORK
 
In-Network
Out-of-Network*
Annual Deductible
Non-embedded
January 1 — December 31
You pay up to
$2,500 per individual
$5,000 per family
You pay up to
$5,000 per individual
$10,000 per family
Coinsurance
You pay 20% AD
You pay 40% AD
Out-of-pocket Maximum
Non-embedded
January 1 — December 31
No more than
$5,000 per individual
$10,000 per family
No more than
$10,000 per individual
$20,000 per family
Preventive Services
You pay
$0 according to government guidelines
You pay
40% AD
Office Visits
Primary Care
Specialist
Chiropractic (10 visits/year)
MDLive Telemedicine
Virtual Care Telehealth **
You pay
20% AD
20% AD
20% AD
10% Deductible Waived
20% Deductible Waived
You pay
40% AD
40% AD
40% AD
Not Covered
40% Deductible Waived
Mental Health Services
Office Visit
Inpatient
You pay
20% AD
20% AD
You pay
40% AD
40% AD
Emergency Services
Urgent Care
Emergency Room
You pay
20% AD
20% AD
You pay
40% AD
Covered as In-Network
Inpatient & Outpatient
Inpatient Hospital
Outpatient Surgery
You pay
20% AD
20% AD
You pay
40% AD
40% AD
Prescription Medication
Generic / Preferred / Brand
Retail (30-day supply)
Mail Order (90-day supply)
You pay 20% AD / 20% AD / 20% AD
You pay 20% AD / 20% AD / 20% AD retail
Health Care Account
Health Savings Account (HSA)
Limited Purpose Flexible Spending Account (LPFSA)
AD: After Deductible
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
** Virtual Care Telehealth visits available and will not be subject to deductible through Dececember 2022

This information is designed to help you choose a benefit plan for 2022 only. Please refer to the Plan Documents provided by the carrier for information regarding coverage, limitations and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.
Deductible Comparison and Medical Terms
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