Copayments and Covered Services
Preventive care services are covered at 100% when you visit an in-network provider. See also Women's Preventive Care and Cancer Screening.
To be covered, a service must meet the plan’s guidelines and medical criteria. All benefits are subject to the allowable amounts determined by DMBA.
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 plan document will govern.
PPO 90
To be covered, an individual must be diagnosed with and treated for a mental disorder included in the current Diagnostic and Statistical Manual of Mental Disorders.
Outpatient
In-network provider: The plan pays 100% after your $25 copayment per visit.
Out-of-network provider: The plan pays 100% of DMBA’s allowable amount after your $25 copayment per visit; you pay $25 plus any remaining amount.
Covered services:
- Diagnostic evaluation
- Individual therapy
- Group therapy
- Medication evaluation and management
Some therapies, such as educational groups and marriage counseling, are not covered. See Exclusions.
Inpatient, partial hospital, and intensive outpatient treatment, and outpatient testing
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Covered services:
- Acute inpatient hospitalization
- Residential treatment services
- Partial hospitalization programs (PHP)
- Intensive outpatient programs (IOP)
- Psychological and neuropsychological testing
Preauthorization is required. In case of emergency, ensure your provider calls DMBA within two business days after the admission or as soon as reasonably possible.
Artificial insemination
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Preauthorization is required.
In vitro fertilization (IVF)
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
The plan pays for services up to $10,000 per lifetime per contract, whether used by the participant, a spouse, a dependent, or a combination thereof.
To be covered, the patient’s spouse must be the donor for all tissue used for an IVF cycle, including but not limited to eggs, sperm, and embryos, and DMBA’s medical criteria must be met.
Preauthorization is required.
Services you receive with IVF, such as surgery, office visits, lab work, and anesthesia, are covered at the appropriate benefit levels for those services and apply to the IVF lifetime benefit limit.
Physician services
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
The plan pays some maternity physician services that are preventive services under the ACA at 100% for in-network providers. See preventive services for details.
To be covered, a licensed medical professional, such as a physician (MD), nurse practitioner (NP), or certified nurse midwife (CNM) must provide the services.
Inpatient
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Covered services:
- Services provided in an inpatient hospital setting
- Newborn services
- Extended hospital stays with preauthorization after two days for a vaginal delivery or after four days for a cesarean section delivery
Services received in other settings may not be covered, including but not limited to home birth (see Exclusions) and non-licensed birthing centers.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
To be covered, a certified or licensed dietician or nutritionist must provide education for an individual diagnosed with an eating disorder, such as anorexia or bulimia, or with celiac disease.
Out-of-network PCP: The plan pays 100% of DMBA’s allowable amount after your $40 copayment; you pay $40 plus any remaining amount. The deductible applies.
In-network specialist: The plan pays 100% after your $50 copayment.
Out-of-network specialist: The plan pays 100% of DMBA’s allowable amount after your $60 copayment; you pay $60 plus any remaining amount. The deductible applies.
You pay an additional $5 for an after-hours visit. Other services, such as lab work and X-rays, are covered at the appropriate benefit levels for those services.
Screenings can be preventive or diagnostic. A preventive screening that results in a diagnosis is considered diagnostic and services will be paid under the diagnostic benefit.
Preventive
In-network provider: The plan pays 100%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Two screenings per lifetime are covered for women.
Diagnostic
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Covered services:
- Bone density scans, once every five years
- Bone density scans, once per year for individuals diagnosed with osteoporosis or osteopenia
PPO 70
To be covered, an individual must be diagnosed with and treated for a mental disorder included in the current Diagnostic and Statistical Manual of Mental Disorders.
Outpatient
In-network provider: The plan pays 100% after your $25 copayment per visit.
Out-of-network provider: The plan pays 100% of DMBA’s allowable amount after your $25 copayment per visit; you pay $25 plus any remaining amount.
Covered services:
- Diagnostic evaluation
- Individual therapy
- Group therapy
- Medication evaluation and management
Some therapies, such as educational groups and marriage counseling, are not covered. See Exclusions.
Inpatient, partial hospital, and intensive outpatient treatment, and outpatient testing
In-network provider: The plan pays 70%; you pay 30%.
Out-of-network provider: The plan pays 50% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Covered services:
- Acute inpatient hospitalization
- Residential treatment services
- Partial hospitalization programs (PHP)
- Intensive outpatient programs (IOP)
- Psychological and neuropsychological testing
Preauthorization is required. In case of emergency, ensure your provider calls DMBA within two business days after the admission or as soon as reasonably possible.
Artificial insemination
In-network provider: The plan pays 70%; you pay 30%.
Out-of-network provider: The plan pays 50% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Preauthorization is required.
In vitro fertilization (IVF)
In-network provider: The plan pays 70%; you pay 30%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
The plan pays for services up to $10,000 per lifetime per contract, whether used by the participant, a spouse, a dependent, or a combination thereof.
To be covered, the patient’s spouse must be the donor for all tissue used for an IVF cycle, including but not limited to eggs, sperm, and embryos, and DMBA’s medical criteria must be met.
Preauthorization is required.
Services you receive with IVF, such as surgery, office visits, lab work, and anesthesia, are covered at the appropriate benefit levels for those services and apply to the IVF lifetime benefit limit.
Physician services
In-network provider: The plan pays 70%; you pay 30%.
Out-of-network provider: The plan pays 50% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
The plan pays some maternity physician services that are preventive services under the ACA at 100% for in-network providers. See preventive services for details.
To be covered, a licensed medical professional, such as a physician (MD), nurse practitioner (NP), or certified nurse midwife (CNM) must provide the services.
Inpatient
In-network provider: The plan pays 70%; you pay 30%.
Out-of-network provider: The plan pays 50% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Covered services:
- Services provided in an inpatient hospital setting
- Newborn services
- Extended hospital stays with preauthorization after two days for a vaginal delivery or after four days for a cesarean section delivery
Services received in other settings may not be covered, including but not limited to home birth (see Exclusions) and non-licensed birthing centers.
Out-of-network provider: The plan pays 50% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
To be covered, a certified or licensed dietician or nutritionist must provide education for an individual diagnosed with an eating disorder, such as anorexia or bulimia, or with celiac disease.
Out-of-network PCP: The plan pays 100% of DMBA’s allowable amount after your $40 copayment; you pay $40 plus any remaining amount. The deductible applies.
In-network specialist: The plan pays 100% after your $50 copayment.
Out-of-network specialist: The plan pays 100% of DMBA’s allowable amount after your $60 copayment; you pay $60 plus any remaining amount. The deductible applies.
You pay an additional $5 for an after-hours visit. Other services, such as lab work and X-rays, are covered at the appropriate benefit levels for those services.
Screenings can be preventive or diagnostic. A preventive screening that results in a diagnosis is considered diagnostic and services will be paid under the diagnostic benefit.
Preventive
In-network provider: The plan pays 100%.
Out-of-network provider: The plan pays 50% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Two screenings per lifetime are covered for women.
Diagnostic
In-network provider: The plan pays 70%; you pay 30%.
Out-of-network provider: The plan pays 50% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Covered services:
- Bone density scans, once every five years
- Bone density scans, once per year for individuals diagnosed with osteoporosis or osteopenia
HSA 80
To be covered, an individual must be diagnosed with and treated for a mental disorder included in the current Diagnostic and Statistical Manual of Mental Disorders.
Outpatient
In-network or out-of-network provider: The plan pays 80% of DMBA’s allowable amount; you pay 20%. The in-network deductible applies.
Covered services:
- Diagnostic evaluation
- Individual therapy
- Group therapy
- Medication evaluation and management
Some therapies, such as educational groups and marriage counseling, are not covered. See Exclusions.
Inpatient, partial hospital, and intensive outpatient treatment, and outpatient testing
In-network provider: The plan pays 70%; you pay 30%.
Out-of-network provider: The plan pays 50% of DMBA’s allowable amount; you pay the remaining amount. The deductible applies.
Covered services:
- Acute inpatient hospitalization
- Residential treatment services
- Partial hospitalization programs (PHP)
- Intensive outpatient programs (IOP)
- Psychological and neuropsychological testing
Preauthorization is required. In case of emergency, ensure your provider calls DMBA within two business days after the admission or as soon as reasonably possible.
Artificial insemination
In-network provider: The plan pays 80%; you pay 20%. The in-network deductible applies.
Out-of-network provider: The plan pays 60% of DMBA’s allowable amount; you pay 40% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
Preauthorization is required.
In vitro fertilization (IVF)
In-network provider: The plan pays 80%; you pay 20%. The in-network deductible applies.
Out-of-network provider: The plan pays 60% of DMBA’s allowable amount; you pay 40% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
The plan pays for services up to $10,000 per lifetime per contract, whether used by the participant, a spouse, a dependent, or a combination thereof.
To be covered, the patient’s spouse must be the donor for all tissue used for an IVF cycle, including but not limited to eggs, sperm, and embryos, and DMBA’s medical criteria must be met.
Preauthorization is required.
Services you receive with IVF, such as surgery, office visits, lab work, and anesthesia, are covered at the appropriate benefit levels for those services and apply to the IVF lifetime benefit limit.
Physician services
In-network provider: The plan pays 80%; you pay 20%. The in-network deductible applies.
Out-of-network provider: The plan pays 60% of DMBA’s allowable amount; you pay 40% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
The plan pays some maternity physician services that are preventive services under the ACA at 100% for in-network providers. See preventive services for details.
To be covered, a licensed medical professional, such as a physician (MD), nurse practitioner (NP), or certified nurse midwife (CNM) must provide the services.
Inpatient
In-network provider: The plan pays 80%; you pay 20%. The in-network deductible applies.
Out-of-network provider: The plan pays 60% of DMBA’s allowable amount; you pay 40% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
Covered services:
- Services provided in an inpatient hospital setting
- Newborn services
- Extended hospital stays with preauthorization after two days for a vaginal delivery or after four days for a cesarean section delivery
Services received in other settings may not be covered, including but not limited to home birth (see Exclusions) and non-licensed birthing centers.
Out-of-network provider: The plan pays 60% of DMBA’s allowable amount; you pay 40% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
To be covered, a certified or licensed dietician or nutritionist must provide education for an individual diagnosed with an eating disorder, such as anorexia or bulimia, or with celiac disease.
Out-of-network provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%. The out-of-network deductible applies.
Other services, such as lab work and X-rays, are covered at the appropriate benefit levels for those services.
Screenings can be preventive or diagnostic. A preventive screening that results in a diagnosis is considered diagnostic and services will be paid under the diagnostic benefit.
Preventive
In-network provider: The plan pays 100%.
Out-of-network provider: The plan pays 60% of DMBA’s allowable amount; you pay 40% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
Two screenings per lifetime are covered for women.
Diagnostic
In-network provider: The plan pays 80%; you pay 20%. The in-network deductible applies.
Out-of-network provider: The plan pays 60% of DMBA’s allowable amount; you pay 40% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
Covered services:
- Bone density scans, once every five years
- Bone density scans, once per year for individuals diagnosed with osteoporosis or osteopenia
HSA 60
To be covered, an individual must be diagnosed with and treated for a mental disorder included in the current Diagnostic and Statistical Manual of Mental Disorders.
Outpatient
In-network or out-of-network provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%. The in-network deductible applies.
Covered services:
- Diagnostic evaluation
- Individual therapy
- Group therapy
- Medication evaluation and management
Some therapies, such as educational groups and marriage counseling, are not covered. See Exclusions.
Inpatient, partial hospital, and intensive outpatient treatment, and outpatient testing
In-network provider: The plan pays 60%; you pay 40%. The in-network deductible applies.
Out-of-network provider: The plan pays 40% of DMBA’s allowable amount; you pay 60% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
Covered services:
- Acute inpatient hospitalization
- Residential treatment services
- Partial hospitalization programs (PHP)
- Intensive outpatient programs (IOP)
- Psychological and neuropsychological testing
Preauthorization is required. In case of emergency, ensure your provider calls DMBA within two business days after the admission or as soon as reasonably possible.
Artificial insemination
In-network provider: The plan pays 60%; you pay 40%. The in-network deductible applies.
Out-of-network provider: The plan pays 40% of DMBA’s allowable amount; you pay 60% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
Preauthorization is required.
In vitro fertilization (IVF)
In-network provider: The plan pays 60%; you pay 40%. The in-network deductible applies.
Out-of-network provider: The plan pays 40% of DMBA’s allowable amount; you pay 60% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
The plan pays for services up to $10,000 per lifetime per contract, whether used by the participant, a spouse, a dependent, or a combination thereof.
To be covered, the patient’s spouse must be the donor for all tissue used for an IVF cycle, including but not limited to eggs, sperm, and embryos, and DMBA’s medical criteria must be met.
Preauthorization is required.
Services you receive with IVF, such as surgery, office visits, lab work, and anesthesia, are covered at the appropriate benefit levels for those services and apply to the IVF lifetime benefit limit.
Physician services
In-network provider: The plan pays 60%; you pay 40%. The in-network deductible applies.
Out-of-network provider: The plan pays 40% of DMBA’s allowable amount; you pay 60% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
The plan pays some maternity physician services that are preventive services under the ACA at 100% for in-network providers. See preventive services for details.
To be covered, a licensed medical professional, such as a physician (MD), nurse practitioner (NP), or certified nurse midwife (CNM) must provide the services.
Inpatient
In-network provider: The plan pays 60%; you pay 40%. The in-network deductible applies.
Out-of-network provider: The plan pays 40% of DMBA’s allowable amount; you pay 60% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
Covered services:
- Services provided in an inpatient hospital setting
- Newborn services
- Extended hospital stays with preauthorization after two days for a vaginal delivery or after four days for a cesarean section delivery
Services received in other settings may not be covered, including but not limited to home birth (see Exclusions) and non-licensed birthing centers.
Out-of-network provider: The plan pays 40% of DMBA’s allowable amount; you pay 60% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
To be covered, a certified or licensed dietician or nutritionist must provide education for an individual diagnosed with an eating disorder, such as anorexia or bulimia, or with celiac disease.
Out-of-network provider: The plan pays 40% of DMBA’s allowable amount; you pay 60%. The out-of-network deductible applies.
Other services, such as lab work and X-rays, are covered at the appropriate benefit levels for those services.
Screenings can be preventive or diagnostic. A preventive screening that results in a diagnosis is considered diagnostic and services will be paid under the diagnostic benefit.
Preventive
In-network provider: The plan pays 100%.
Out-of-network provider: The plan pays 40% of DMBA’s allowable amount; you pay 60% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
Two screenings per lifetime are covered for women.
Diagnostic
In-network provider: The plan pays 60%; you pay 40%. The in-network deductible applies.
Out-of-network provider: The plan pays 40% of DMBA’s allowable amount; you pay 60% and all expenses that exceed the plan’s allowable amount. The out-of-network deductible applies.
Covered services:
- Bone density scans, once every five years
- Bone density scans, once per year for individuals diagnosed with osteoporosis or osteopenia
Deseret Choice Hawaii
To be covered, an individual must be diagnosed with and treated for a mental disorder included in the current Diagnostic and Statistical Manual of Mental Disorders.
Outpatient
In-network or out-of-network provider: The plan pays 100% after your $15 copayment per visit.
Covered services:
- Diagnostic evaluation
- Individual therapy
- Group therapy
- Medication evaluation and management
Some therapies, such as educational groups and marriage counseling, are not covered. See Exclusion 10.2.
Inpatient, partial hospital, and intensive outpatient treatment, and outpatient testing
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay 30%.
Covered services:
- Acute inpatient hospitalization
- Residential treatment services
- Partial hospitalization programs (PHP)
- Intensive outpatient programs (IOP)
- Psychological and neuropsychological testing
Preauthorization is required. In case of emergency, ensure your provider calls DMBA within two business days after the admission or as soon as reasonably possible.
Artificial insemination
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay 30%.
Preauthorization is required.
In vitro fertilization (IVF)
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay 30%. The plan pays for in vitro fertilization one time for a participant, whether used by the participant, a spouse, a dependent, or a combination thereof.
To be covered, the patient’s spouse must be the donor for all tissue used for an IVF cycle, including but not limited to eggs, sperm, and embryos, and DMBA’s medical criteria must be met.
Preauthorization is required.
Services you receive with IVF, such as surgery, office visits, lab work, and anesthesia, are covered at the appropriate benefit levels for those services.
Physician services
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay 30%.
The plan pays some maternity physician services which are preventive services under the ACA at 100% for in-network providers. See preventive services for details.
To be covered, a licensed medical professional, such as a physician (MD), nurse practitioner (NP), or certified nurse midwife (CNM) must provide the services.
Inpatient
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay 30%.
Covered services:
- Services provided in an inpatient hospital setting
- Newborn services
- Extended hospital stays with preauthorization after two days for a vaginal delivery or after four days for a cesarean section delivery
Services received in other settings may not be covered, including but not limited to home birth (see Exclusion 4.8) and non-licensed birthing centers.
To be covered, a certified or licensed dietician or nutritionist must provide education for an individual diagnosed with an eating disorder, such as anorexia or bulimia, or with celiac disease.
In-network specialist: The plan pays 100% after your $20 copayment. Out-of-network provider: The plan pays 80% of DMBA’s allowable amount; you pay 20% after your $20 copayment.
You pay an additional $5 for an after-hours visit.
Other services, such as lab work and X-rays, are covered at the appropriate benefit levels for those services.
Screenings can be preventive or diagnostic. A preventive screening that results in a diagnosis is considered diagnostic and services will be paid under the diagnostic benefit.
Preventive
In-network provider: The plan pays 100%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay 30%.
Two screenings per lifetime are covered for women.
Diagnostic
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay 30%.
Covered services:
- Bone density scans, once every five years
- Bone density scans, once per year for individuals diagnosed with osteoporosis or osteopenia
Diagnostic
In-network provider: The plan pays 90%; you pay 10%.
Out-of-network provider: The plan pays 70% of DMBA’s allowable amount; you pay 30%.
Covered services:
- Bone density scans, once every five years
- Bone density scans, once per year for individuals diagnosed with osteoporosis or osteopenia
DMBA Navigation Services
Do you need help understanding your options so you can make informed decisions about your medical or mental healthcare?
We can assist you with the following:
- Getting timely access to care when you need it most
- Understanding your treatment options and available services
- Finding providers and resources that fit your needs
- Coordinating next steps after a hospital stay
Ready to get started? Call 801‑578‑5600 or 1‑800‑777‑3622 and ask for Navigation Services.
Full navigation benefits are available with PPO 90, PPO 70, HSA 80, and HSA 60 plans.