Information about your insurance and the coverage it gives
EMIA Pool
September 01, 2020 - August 31, 2021
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 Not Covered Not Covered
Orthognathic/Mandibular Osteotomy Not Covered Not Covered
Total Parenteral Nutrition (TPN) ♦20% Not Covered
Initial assessment and diagnosis of Primary Infertility Not Covered 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, 2020 - August 31, 2021 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) $5,800 / $11,600 $7,500 / $15,000
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 - 20%
♦Preferred - 20%
♦Non-Preferred - 20%
Non-Participating Pharmacy Not Covered
Mail Order (90 day supply) ♦Generic - 20%
♦Preferred - 20%
♦Non-Preferred - 20%
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%
 
 

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