Value Silver 2500 (2022) - Box Elder - UT

Value Silver 2500 (2022) - Box Elder - UT

  64 InfoPreferred Score Good

specifications

  • Premium 452.39 Dollar(s)
  • Deductibles 2500 Dollar(s)
  • Out of Pocket Maximum 8700 Dollar(s)
  • Covered Benefits 29 out of 40

Key Features

$ 452.39
Premium
Good
$ 2500
Deductibles
Very Good
$ 8700
Out of Pocket Maximum
Poor
29 / 40
Covered Benefits
Average

  • Overview

    Plan ID: 68781UT0020024
    Plan Type: HMO
    Metal Level: Silver
    SM Rating: 64
    Covered Benefits: 29
    County: Box Elder
    FIPS County Code: 49003
    State: UT

  • Cost of Medical Sharing

    Premium: 452.39
    EHB Premium: 448.18
    EHB Percent of Total Premium: 99
    Deductibles: 2500
    Out of Pocket Maximum: 8700

  • Cost Sharing

    Adult Dental Care Details: Benefit Not Covered
    Child Dental Care Details: Benefit Not Covered
    Child Dental Check Up: $60
    Adult Major Dental Care: Benefit Not Covered
    Child Major Dental Care: Benefit Not Covered
    Adult Routine Dental Services: Benefit Not Covered
    Eye Glasses for Children: 50% Coinsurance after deductible
    Adult Routine Eye Exam Details: No Charge
    Child Routine Eye Exam Details: No Charge
    Hearing Aids Details: Benefit Not Covered
    Bariatric Surgery: Benefit Not Covered
    Chemotherapy: 50% Coinsurance after deductible
    Chiropractic Care: Benefit Not Covered
    Dialysis: 50% Coinsurance after deductible
    Durable Medical Equipment: 50% Coinsurance after deductible
    Emergency Room Services: $600 Copay after deductible
    Emergency Transportation Ambulance: 50% Coinsurance after deductible
    Habilitation Services: $60
    Imaging (CT, Pet, MRIS Scan): 50% Coinsurance after deductible
    Infertility Treatment: Benefit Not Covered
    Inpatient Hospital Services: 50% Coinsurance after deductible
    Inpatient Physician and Surgical Services: 50% Coinsurance after deductible
    Laboratory Outpatient and Professional Services: No Charge After Deductible
    Mental Behavioral Health Inpatient Services: 50% Coinsurance after deductible
    Mental Behavioral Health Outpatient Services: 50% Coinsurance after deductible
    Adult Orthodontia: Benefit Not Covered
    Child Orthodontia: Benefit Not Covered
    Outpatient Facility Fee: 50% Coinsurance after deductible
    Outpatient Rehabilitation Services: $60
    Outpatient Surgery Services: 50% Coinsurance after deductible
    Preventive Care Screening Immunization: No Charge
    Primary Care Visit: $35 Copay after deductible
    Private Duty Nursing: 50% Coinsurance after deductible
    Skilled Nursing Facility: 50% Coinsurance after deductible
    Specialist Visit: $60 Copay after deductible
    XRays 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_ds
    Generic Drugs: $15
    Non Preferred Brand Drugs: 50% Coinsurance after deductible
    Preferred Brand Drugs: 25% Coinsurance after deductible
    Specialty Drugs: 50% Coinsurance after deductible

  • Benefits

    Dental Benefits: 1
    Vision Benefits: 3
    Hearing Benefits: 0
    Other Benefits: 25
    Adult Dental Care:
    Child Dental Care:
    Adult Routine Eye Exam: 1
    Child Routine Eye Exam: 1
    Hearing 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=X
    Benefits Summary URL: https://selecthealth.org/shsc91/WebApi/CommercialPlans?id=I40A1740&doctype=1
    Brochure 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 Dependent
    Issuer: SelectHealth
    Issuer ID: 68781
    Issuer Shop URL: http://selecthealth.org/
    Customer Service Toll free Number: 1-800-538-5038
    Area: Rating Area 2

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