Cost of Coverage (Monthly)
Blue Shield UT Select Network Core w/ HRA* - Utah Salaried Employees Only
January 2025 - December 2025
Your Cost
Employee Only: $0 per month
Employee + Partner: $210 per month
Employee + Kid(s): $153 per month
Employee + Family: $412 per month
*This plan includes a company sponsored Health Reimbursement Account (HRA) of $375 for an individual, $750 for a family. HRA dollars can be used to fund copays, out-of-pocket expenses towards your deductible, prescription costs, among other eligible expenses.
What's Covered
In-Network
Annual Deductible: $750 per individual, $1,500 per family
Annual Out-of-Pocket Max: $3,500 per individual, $7,000 per family
Lifetime Max: unlimited
Primary Office Visit: $25 copay
Specialist: $40 copay
Preventive Services: $0
Urgent Care center services: $25/visit
Standard Services (not limited to): 20% coinsurance
Allergy
Inpatient/outpatient hospitalization
Lab and x-Ray
Chiropractic Services: $25/visit, up to 20 visits per year
Advance Imaging: $100 copay + 20% coinsurance
Emergency Room: $150 copay + 20% coinsurance
OptumRx:
Pharmacy (Standard): supply limit 30 days
Tier 1: $10 copay
Tier 2: $35 copay
Tier 3: $60 copay
Tier 4: 30% coinsurance up to $200
Contraceptive drugs and devices: $0
Pharmacy (Mail Order): supply limit 90 days
Tier 1: $20 copay
Tier 2: $70 copay
Tier 3: $120 copay
Tier 4: 30% coinsurance up to $400
Out-of-Network
Annual Deductible: $1,500 per individual, $3,000 per family
Annual Out-of-Pocket Max: $7,000 per individual, $14,000 per family
Lifetime Max: unlimited
Primary Office Visit: 40% coinsurance
Specialist: 40% coinsurance
Preventive Services: not covered
Urgent Care center services: 40%
Standard Services (not limited to): 40% coinsurance
Allergy
Inpatient/outpatient hospitalization
Lab and x-Ray
Chiropractic Services: 40% coinsurance
Advance Imaging: 40% coinsurance
Emergency Room: $150 copay + 20% coinsurance
OptumRx:
Pharmacy (Standard): supply limit 30 days
Tier 1: 25% plus $10 copay
Tier 2: 25% plus $35 copay
Tier 3: 25% plus $60 copay
Tier 4: 30% up to $200/prescription plus 25% of purchase price
Contraceptive drugs and devices: Applicable Tier 1, 2 or 3 copay
Pharmacy (Mail Order): supply limit 90 days
Tier 1: not covered
Tier 2: not covered
Tier 3: not covered
Tier 4: not covered
Plan Documents
Heading to an Appointment?
Below you'll find what you need to take with you to your appointments.
Group Number: 54027
Blue Shield ID Card: A digital card is available from the Blue Shield app and member portal if you don’t have your physical card.