This short list of benefits applies to behavioral and mental health conditions and is specific to each plan. Please select your plan to see your benefits with their copayments (listed as a dollar amount), coinsurance (your share of the cost listed as a percentage of the provider’s total charge), and what services are covered under each benefit. For a complete list of your medical benefits, log in to www.dmba.com. Navigate to My Plans and under Summary Plan Descriptions (Handbooks) select your plan.
To be a covered service, the healthcare you receive must be medically necessary, meet the plan’s guidelines and medical criteria, and be provided by a licensed practitioner of the healing arts. 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.
Contracted provider: The plan pays 90%; you pay 10%.
Non-contracted provider: The plan pays 80% of DMBA’s allowable amount; you pay 20%. The annual deductible applies.
To be covered, a board-certified behavior analyst (BCBA or BCBA-D) must provide therapy for an individual with a confirmed autism spectrum disorder diagnosis by a qualified provider (i.e., psychiatrist, psychologist, neurologist, or developmental pediatrician).
You must preauthorize, including the initial assessment.
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.
Contracted provider: The plan pays 100% after your $20 copayment per visit.
Non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your $25 copayment per visit.
Covered services:
Some therapies, such as educational groups, are not covered.
Contracted provider: The plan pays 90%; you pay 10%.
Non-contracted provider: The plan pays 80% of DMBA’s allowable amount; you pay 20%. The annual deductible applies.
Covered services:
Preauthorization is required. In case of emergency, call DMBA within two business days after the admission or as soon as reasonably possible.
Contracted or non-contracted provider: The plan pays 90% of DMBA’s allowable amount; you pay 10% after your $100 copayment per visit.
If you receive follow-up care at the emergency room, you’re responsible for another $100 copayment plus your 10% coinsurance.
If your emergency is not life threatening, see Urgent care for a less expensive alternative.
Other services you receive during an emergency room visit that are billed separately are covered at the appropriate benefit levels for those services.
If the visit results in an inpatient hospital stay, you must preauthorize within two business days of admission or as soon as reasonably possible.
Contracted provider: The plan pays 90%; you pay 10%.
Non-contracted provider: The plan pays 80% of DMBA’s allowable amount; you pay 20%. The annual 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.
Contracted or non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your $45 copayment per visit.
For a less expensive alternative, consider using Intermountain Connect Care, a telemedicine service. The plan pays 100% after your $20 copayment. If your medical need is not treatable in a virtual setting, you will not be charged for the Connect Care telemedicine visit.
Other services you receive during an urgent care visit are covered at 70% of DMBA’s allowable amount or the appropriate benefit level, whichever is higher.
Contracted provider: The plan pays 90%; you pay 10%.
Non-contracted provider: The plan pays 80% of DMBA’s allowable amount; you pay 20%. The annual deductible applies.
To be covered, a board-certified behavior analyst (BCBA or BCBA-D) must provide therapy for an individual with a confirmed autism spectrum disorder diagnosis by a qualified provider (i.e., psychiatrist, psychologist, neurologist, or developmental pediatrician).
You must preauthorize, including the initial assessment.
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.
Contracted provider: The plan pays 100% after your $20 copayment per visit.
Non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your $35 copayment per visit.
Covered services:
Some therapies, such as educational groups, are not covered.
Contracted provider: The plan pays 90%; you pay 10%.
Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%.
Covered services:
Preauthorization is required. In case of emergency, call DMBA within two business days after the admission or as soon as reasonably possible.
Contracted or non-contracted provider: The plan pays 90% of DMBA’s allowable amount; you pay 10% after your $100 copayment per visit.
If you receive follow-up care at the emergency room, you’re responsible for another $100 copayment plus your 10% coinsurance.
If your emergency is not life threatening, see Urgent care for a less expensive alternative.
Other services you receive during an emergency room visit that are billed separately are covered at the appropriate benefit levels for those services.
If the visit results in an inpatient hospital stay, you must preauthorize within two business days of admission or as soon as reasonably possible.
Contracted provider: The plan pays 90%; you pay 10%.
Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%.
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.
Contracted or non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your $45 copayment per visit.
For a less expensive alternative, consider using Intermountain Connect Care, a telemedicine service. The plan pays 100% after your $20 copayment. If your medical need is not treatable in a virtual setting, you will not be charged for the Connect Care telemedicine visit.
Other services you receive during an urgent care visit are covered at 90% of DMBA’s allowable amount or the appropriate benefit level, whichever is higher.
Contracted provider: The plan pays 70%; you pay 30%.
Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%. The annual deductible applies.
To be covered, a board-certified behavior analyst (BCBA or BCBA-D) must provide therapy for an individual with a confirmed autism spectrum disorder diagnosis by a qualified provider (i.e., psychiatrist, psychologist, neurologist, or developmental pediatrician).
You must preauthorize, including the initial assessment.
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.
Contracted provider: The plan pays 100% after your $20 copayment per visit.
Non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your $25 copayment per visit.
Covered services:
Some therapies, such as educational groups, are not covered.
Contracted provider: The plan pays 70%; you pay 30%.
Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%. The annual deductible applies.
Covered services:
Preauthorization is required. In case of emergency, call DMBA within two business days after the admission or as soon as reasonably possible.
Contracted or non-contracted provider: The plan pays 70% of DMBA’s allowable amount; you pay 30% after your $100 copayment per visit.
If you receive follow-up care at the emergency room, you’re responsible for another $100 copayment plus your 30% coinsurance.
If your emergency is not life threatening, see Urgent care for a less expensive alternative.
Other services you receive during an emergency room visit that are billed separately are covered at the appropriate benefit levels for those services.
If the visit results in an inpatient hospital stay, you must preauthorize within two business days of admission or as soon as reasonably possible.
Contracted provider: The plan pays 70%; you pay 30%.
Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%. The annual 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.
Contracted or non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your $45 copayment per visit.
For a less expensive alternative, consider using Intermountain Connect Care, a telemedicine service. The plan pays 100% after your $20 copayment. If your medical need is not treatable in a virtual setting, you will not be charged for the Connect Care telemedicine visit.
Other services you receive during an urgent care visit are covered at 70% of DMBA’s allowable amount or the appropriate benefit level, whichever is higher.
Contracted provider: The plan pays 70%; you pay 30%. The annual deductible applies.
Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%. The annual deductible applies.
To be covered, a board-certified behavior analyst (BCBA or BCBA-D) must provide therapy for an individual with a confirmed autism spectrum disorder diagnosis by a qualified provider (i.e., psychiatrist, psychologist, neurologist, or developmental pediatrician).
You must preauthorize, including the initial assessment.
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.
Contracted provider: The plan pays 100% after your $20 copayment per visit.
Non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your $25 copayment per visit.
Covered services:
Some therapies, such as educational groups, are not covered.
Contracted provider: The plan pays 70%; you pay 30%. The annual deductible applies.
Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%. The annual deductible applies.
Covered services:
Preauthorization is required. In case of emergency, call DMBA within two business days after the admission or as soon as reasonably possible.
Contracted or non-contracted provider: The plan pays 70% of DMBA’s allowable amount; you pay 30% after your $100 copayment per visit. The annual deductible applies.
If you receive follow-up care at the emergency room, you’re responsible for another $100 copayment plus your 30% coinsurance.
If your emergency is not life threatening, see Urgent care for a less expensive alternative.
Other services you receive during an emergency room visit that are billed separately are covered at the appropriate benefit levels for those services.
If the visit results in an inpatient hospital stay, you must preauthorize within two business days of admission or as soon as reasonably possible.
Contracted provider: The plan pays 70%; you pay 30%. The annual deductible applies.
Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%. The annual 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.
Contracted or non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your $55 copayment per visit.
For a less expensive alternative, consider using Intermountain Connect Care, a telemedicine service. The plan pays 100% after your $20 copayment. If your medical need is not treatable in a virtual setting, you will not be charged for the Connect Care telemedicine visit.
Other services you receive during an urgent care visit are covered at 70% of DMBA’s allowable amount or the appropriate benefit level, whichever is higher.
Contracted provider: The plan pays 90%; you pay 10%.
Non-contracted provider: The plan pays 70% of DMBA’s allowable amount; you pay 30%.
To be covered, a board-certified behavior analyst (BCBA or BCBA-D) must provide therapy for an individual with a confirmed autism spectrum disorder diagnosis by a qualified provider (i.e., psychiatrist, psychologist, neurologist, or developmental pediatrician).
You must preauthorize, including the initial assessment.
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.
Contracted provider: The plan pays 100% after your $15 copayment per visit.
Non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your $20 copayment per visit.
Covered services:
Some therapies, such as educational groups, are not covered.
Contracted provider: The plan pays 90%; you pay 10%.
Non-contracted provider: The plan pays 70% of DMBA’s allowable amount; you pay 30%. The annual deductible applies.
Covered services:
Preauthorization may be required. In case of emergency, call DMBA within two business days after the admission or as soon as reasonably possible.
Contracted or non-contracted provider: The plan pays 90% of DMBA’s allowable amount; you pay 10% after your $75 copayment per visit.
If you receive follow-up care at the emergency room, you’re responsible for another $75 copayment plus your 10% coinsurance.
If your emergency is not life threatening, see Urgent care for a less expensive alternative.
Other services you receive during an emergency room visit that are billed separately are covered at the appropriate benefit levels for those services.
If the visit results in an inpatient hospital stay, you must preauthorize within two business days of admission or as soon as reasonably possible.
Contracted or non-contracted provider: The plan pays 90% of DMBA’s allowable amount; you pay 10%.
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.
Contracted or non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your $25 copayment per visit.
For a less expensive alternative, consider using Intermountain Connect Care, a telemedicine service. The plan pays 100% after your $15 copayment. If your medical need is not treatable in a virtual setting, you will not be charged for the Connect Care telemedicine visit.
Other services you receive during an urgent care visit are covered at 90% of DMBA’s allowable amount or the appropriate benefit level, whichever is higher.