Value Silver 2500 (2022) - Utah - UT
65
InfoPreferred Score
Good
specifications
- Premium 443.77 Dollar(s)
- Deductibles 2500 Dollar(s)
- Out of Pocket Maximum 8700 Dollar(s)
- Covered Benefits 29 out of 40
Key Features
$ 443.77
Premium
Good
$ 2500
Deductibles
Very Good
$ 8700
Out of Pocket Maximum
Poor
29 / 40
Covered Benefits
Average
-
Overview
Plan ID: 68781UT0020024Plan Type: HMOMetal Level: SilverCovered Benefits: 29County: UtahFIPS County Code: 49049State: UTSM Rating: 65 -
Cost of Medical Sharing
Premium: 443.77EHB Premium: 439.64EHB Percent of Total Premium: 99Deductibles: 2500Out of Pocket Maximum: 8700 -
Cost Sharing
Adult Dental Care Details: Benefit Not CoveredChild Dental Care Details: Benefit Not CoveredChild Dental Check Up: $60Adult Major Dental Care: Benefit Not CoveredChild Major Dental Care: Benefit Not CoveredAdult Routine Dental Services: Benefit Not CoveredEye Glasses for Children: 50% Coinsurance after deductibleAdult Routine Eye Exam Details: No ChargeChild Routine Eye Exam Details: No ChargeHearing Aids Details: Benefit Not CoveredBariatric Surgery: Benefit Not CoveredChemotherapy: 50% Coinsurance after deductibleChiropractic Care: Benefit Not CoveredDialysis: 50% Coinsurance after deductibleDurable Medical Equipment: 50% Coinsurance after deductibleEmergency Room Services: $600 Copay after deductibleEmergency Transportation Ambulance: 50% Coinsurance after deductibleHabilitation Services: $60Imaging (CT, Pet, MRIS Scan): 50% Coinsurance after deductibleInfertility Treatment: Benefit Not CoveredInpatient Hospital Services: 50% Coinsurance after deductibleInpatient Physician and Surgical Services: 50% Coinsurance after deductibleLaboratory Outpatient and Professional Services: No Charge After DeductibleMental Behavioral Health Inpatient Services: 50% Coinsurance after deductibleMental Behavioral Health Outpatient Services: 50% Coinsurance after deductibleAdult Orthodontia: Benefit Not CoveredChild Orthodontia: Benefit Not CoveredOutpatient Facility Fee: 50% Coinsurance after deductibleOutpatient Rehabilitation Services: $60Outpatient Surgery Services: 50% Coinsurance after deductiblePreventive Care Screening Immunization: No ChargePrimary Care Visit: $35 Copay after deductiblePrivate Duty Nursing: 50% Coinsurance after deductibleSkilled Nursing Facility: 50% Coinsurance after deductibleSpecialist Visit: $60 Copay after deductibleXRays and Diagnostic Imaging: No Charge After Deductible -
Prescription Drug Coverage
List of Covered Drugs URL: https://selecthealth.rxeob.com/mdb_sh/public/router?account=rxc_t5_ut_dsGeneric Drugs: $15Non Preferred Brand Drugs: 50% Coinsurance after deductiblePreferred Brand Drugs: 25% Coinsurance after deductibleSpecialty Drugs: 50% Coinsurance after deductible -
Benefits
Dental Benefits: 1Vision Benefits: 3Hearing Benefits: 0Other Benefits: 25Adult Dental Care:Child Dental Care:Adult Routine Eye Exam: 1Child Routine Eye Exam: 1Hearing Aids:National Network Available:Health Savings Account Eligibility:Disease Management Programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure and High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs -
Plan Documents
Provider Directory URL: https://selecthealth.org/find-a-doctor?state=UT&selectHealthPlan=XBenefits Summary URL: https://selecthealth.org/shsc91/WebApi/CommercialPlans?id=I40A1740&doctype=1Brochure URL: https://selecthealth.org/shsc91/WebApi/CommercialPlans?id=I40A1740&doctype=3 -
Policy Issuer Details
Eligible Dependents: Self, Spouse, Child, Stepson or Stepdaughter, Life Partner, Ward, Sponsored DependentIssuer: SelectHealthIssuer ID: 68781Issuer Shop URL: http://selecthealth.org/Customer Service Toll free Number: 1-800-538-5038Area: Rating Area 4
View similar products
80
InfoPreferred Score
Excellent
Med Benchmark Expanded Bronze 0 Copay Plan (2022) - Utah - UT
82
InfoPreferred Score
Excellent