Signature Benchmark Silver 5900 Medical Deductible - 68781UT0200014 Health Insurance Plan

SelectHealth health insurance plan with the Plan ID 68781UT0200014. The plan is called Signature Benchmark Silver 5900 Medical Deductible.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.16% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 12.84% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 68781UT0200014
Health Insurance Plan Year 2025
State Utah
Health Insurance Issuer SelectHealth
Plan Formulary Description URL Formulary URL
Health Insurance Plan Variant 68781UT0200014-05
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Utah All US States
All 13831 15431
PCP 1824 2078
Allergy 8 9
OB/GYN 73 91
Dentists 1068 1202
Available Variants of the Health Plan

Standard Off Exchange Plan - 68781UT0200014-00

Standard On Exchange Plan - 68781UT0200014-01

Open to Indians below 300% FPL - 68781UT0200014-02

Open to Indians above 300% FPL - 68781UT0200014-03

73% AV Silver Plan - 68781UT0200014-04

87% AV Silver Plan - 68781UT0200014-05

94% AV Silver Plan - 68781UT0200014-06

Last Plan Update Date Wed, 23 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Signature Benchmark Silver 5900 Medical Deductible Health Insurance Plan, 68781UT0200014-05

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
NO
Acupuncture
NO
Allergy Testing
YES

$30.00

100.00%
Autism Spectrum Disorders

Covered as required by state law.

YES

25.00%

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

50.00%

100.00%
Chiropractic Care
NO
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

25.00%

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

25.00%

100.00%
Dialysis
YES

25.00%

100.00%
Durable Medical Equipment

Exclusions: Certain limitations and exclusions exist. Refer to the plan materials for more information.

YES

25.00%

100.00%
Emergency Room Services
YES

$350.00

$350.00
Emergency Transportation/Ambulance
YES

25.00%

25.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Exclusions: Frames are not covered

YES

25.00%

100.00%
Gender Affirming Care
NO
Generic Drugs

Certain generic and brand name drugs have lower cost sharing than the generic tier

YES

$25.00

$25.00
Habilitation Services

Limit: 20.0 Visit(s) per Year

Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits.

YES

$30.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 30.0 Visit(s) per Year

YES

25.00%

100.00%
Hospice Services

Limit: 6.0 Months per 3 Years

YES

25.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$125.00

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

25.00%

100.00%
Inherited Metabolic Disorder - PKU
YES

$30.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

25.00%

100.00%
Inpatient Physician and Surgical Services
YES

25.00%

100.00%
Laboratory Outpatient and Professional Services
YES

$10.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Exclusions: Certain limitations and exclusions exist. Refer to the plan materials for more information.

YES

25.00%

100.00%
Mental/Behavioral Health Outpatient Services

Exclusions: Certain limitations and exclusions exist. Refer to the plan materials for more information.

Office visits for Mental/Behavioral Health Outpatient Services: please refer to the Primary Care Visit for cost sharing information. All other outpatient services (e.g., partial hospitalization, day treatment, intensive outpatient) may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

YES

25.00%

100.00%
Non-Preferred Brand Drugs

The Hepatitis C Virus (HCV) drugs covered on non-preferred brand tier are eligible to receive a rebate from the drug manufacturer. The member out-of-pocket costs will be applied to the deductible and the maximum out-of-pocket.

YES

25% Coinsurance after deductible

25% Coinsurance after deductible
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$0.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

A procedure in a Freestanding Ambulatory Surgery Center, will cost the member less than the amount shown for other outpatient facilities.

YES

25.00%

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have a combined limit of 30 days.

YES

$25.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00%

100.00%
Preferred Brand Drugs
YES

15% Coinsurance after deductible

15% Coinsurance after deductible
Prenatal and Postnatal Care
YES

$0.00

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$0.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
NO
Radiation
YES

25.00%

100.00%
Reconstructive Surgery

Exclusions: Covered only in limited circumstances

YES

25.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Days per Year

Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have a combined limit of 30 days.

YES

$30.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Days per Year

Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have a combined limit of 30 days.

YES

$30.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

$30.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Year

YES

25.00%

100.00%
Specialist Visit
YES

$30.00

100.00%
Specialty Drugs
YES

50.00% Coinsurance after deductible

50% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services

Exclusions: Certain limitations and exclusions exist. Refer to the plan materials for more information.

YES

25.00%

100.00%
Substance Abuse Disorder Outpatient Services

Exclusions: Certain limitations and exclusions exist. Refer to the plan materials for more information.

Office visits for Mental/Behavioral Health Outpatient Services: please refer to the Primary Care Visit for cost sharing information

YES

25.00%

100.00%
Transplant

Exclusions: Covered only in limited circumstances

YES

25.00%

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$30.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$10.00

100.00%

Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan Variant 68781UT0200014-05 Attributes

Plan Attribute Value
AV Calculator Output Number 0.8715825024463449
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type 87% AV Level Silver Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group $600 per group
Drug EHB Deductible, Combined In/Out of Network, Family Per Person $200 per person
Drug EHB Deductible, Combined In/Out of Network, Individual $200
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 25.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group per group not applicable
Drug EHB Deductible, In Network (Tier 1), Family Per Person per person not applicable
Drug EHB Deductible, In Network (Tier 1), Individual Not Applicable
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID UTF016
Formulary URL URL
HIOS Product ID 68781UT020
Import Date 2024-10-23 20:01:37
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 68781
Issuer Marketplace Marketing Name Select Health
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 25.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 1), Individual $0
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID UTN003
Out of Country Coverage No
Out of Country Coverage Description Urgent or emergency care only
Out of Service Area Coverage No
Out of Service Area Coverage Description Urgent or emergency care only
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 68781UT0200014-05
Plan Level Exclusions Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses; computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.
Plan Marketing Name Signature Benchmark Silver 5900 Medical Deductible
Plan Type HMO
Plan Variant Marketing Name Signature Benchmark Silver 0 Medical Deductible
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,600
SBC Scenario, Having a Baby, Copayment $400
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $200
SBC Scenario, Having Diabetes, Copayment $300
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $300
SBC Scenario, Treatment of a Simple Fracture, Copayment $1,100
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID UTS003
Source Name SERFF
Plan ID 68781UT0200014
State Code UT
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $6000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $3000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $3,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Signature Benchmark Silver 5900 Medical Deductible Health Insurance Plan, 68781UT0200014

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Signature Benchmark Silver 5900 Medical Deductible, 68781UT0200014 Health Insurance Plan, 68781UT0200014

  • Does Signature Benchmark Silver 5900 Medical Deductible Health Insurance Plan, 68781UT0200014 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (68781UT0200014) Health Insurance Plan, Variant (68781UT0200014-05) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (68781UT0200014) Health Insurance Plan, Variant (68781UT0200014-05) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: Urgent or emergency care only

    Does (68781UT0200014) Health Insurance Plan, Variant (68781UT0200014-05) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Urgent or emergency care only

    Does (68781UT0200014) Health Insurance Plan, Variant (68781UT0200014-05) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan, Variant (68781UT0200014-05) offer Disease Management Programs for Asthma?

    Yes, the Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan Variant 68781UT0200014-05 offers Disease Management Program for Asthma.

    Does Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan, Variant (68781UT0200014-05) offer Disease Management Programs for Heart disease?

    Yes, the Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan Variant 68781UT0200014-05 offers Disease Management Program for Heart disease.

    Does Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan, Variant (68781UT0200014-05) offer Disease Management Programs for Depression?

    Yes, the Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan Variant 68781UT0200014-05 offers Disease Management Program for Depression.

    Does Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan, Variant (68781UT0200014-05) offer Disease Management Programs for Diabetes?

    Yes, the Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan Variant 68781UT0200014-05 offers Disease Management Program for Diabetes.

    Does Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan, Variant (68781UT0200014-05) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan Variant 68781UT0200014-05 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan, Variant (68781UT0200014-05) offer Disease Management Programs for Low back pain?

    Yes, the Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan Variant 68781UT0200014-05 offers Disease Management Program for Low back pain.

    Does Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan, Variant (68781UT0200014-05) offer Disease Management Programs for Pregnancy?

    Yes, the Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan Variant 68781UT0200014-05 offers Disease Management Program for Pregnancy.

    Does Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan, Variant (68781UT0200014-05) offer Disease Management Programs for Weight loss programs?

    Yes, the Signature Benchmark Silver 0 Medical Deductible Health Insurance Plan Variant 68781UT0200014-05 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API