ZIP Code
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Applicant Info
Applicant
Date of birth
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Gender
male
female
Income
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Zip Code	84120 (edit)
Applicant	12/14/1984 Male (edit)

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Insurance Type	ACA (Obamacare)
Plan Name	Med Expanded Bronze 4800 Copay Plan - no deductible for one urgent care and all PCP visits
Plan ID	qhp-68781UT0020043
Plan Year	2020
Insurance Provider	SelectHealth
Metal Level	Expanded Bronze
Plan Type	HMO
Deductible	$4,800
Out-of-Pocket Maximum	$7,900
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$25 Copay
Specialist Visit	$60 Copay
Laboratory Outpatient and Professional Services	No Charge after deductible
X-rays and Diagnostic Imaging	No Charge after deductible
Deductible - Family	$9600
Out-of-Pocket Maximum - Family	$15800

Prescription drug coverage
Generic Drugs	$25 Copay
Preferred Brand Drugs	$55 Copay
Non-Preferred Brand Drugs	$70 Copay
Specialty Drugs	50% Coinsurance after deductible

Access to doctors and hospitals
Provider directory URL	http://selecthealth.org/providers/default.aspx?medical=med&dental=classic

Hospital services
Emergency Room Services	$600 Copay
Inpatient Hospital Services (e.g., Hospital Stay)	40% Coinsurance after deductible
Inpatient Physician and Surgical Services	$650 Copay

Maternity
Prenatal and Postnatal Care	40.00% Coinsurance after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	40.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services	Not Applicable

Vision Coverage
Routine Eye Exam for Children	No Charge
Eye Glasses for Children	40.00% Coinsurance after deductible

Exclusions and Limitations
More Included Benefits	Other Practitioner Office Visit (Nurse, Physician Assistant) Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services Hospice Services Private-Duty Nursing Urgent Care Centers or Facilities Home Health Care Services Inpatient Physician and Surgical Services Skilled Nursing Facility Outpatient Rehabilitation Services Habilitation Services Durable Medical Equipment Imaging (CT/PET Scans, MRIs) Preventive Care/Screening/Immunization Dental Check-Up for Children Rehabilitative Speech Therapy Rehabilitative Occupational and Rehabilitative Physical Therapy Well Baby Visits and Care Transplant Accidental Dental Dialysis Allergy Testing Chemotherapy Radiation Diabetes Education Prosthetic Devices Infusion Therapy Nutritional Counseling Reconstructive Surgery Inherited Metabolic Disorder - PKU Autism Spectrum Disorders
More Excluded Benefits	Infertility Treatment Long-Term/Custodial Nursing Home Care Bariatric Surgery Cosmetic Surgery Chiropractic Care Hearing Aids Routine Foot Care Acupuncture Weight Loss Programs Abortion for Which Public Funding is Prohibited Treatment for Temporomandibular Joint Disorders

Exclusions and Limitations

More Included Benefits

Other Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Private-Duty Nursing
Urgent Care Centers or Facilities
Home Health Care Services
Inpatient Physician and Surgical Services
Skilled Nursing Facility
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Dental Check-Up for Children
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Transplant
Accidental Dental
Dialysis
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Nutritional Counseling
Reconstructive Surgery
Inherited Metabolic Disorder - PKU
Autism Spectrum Disorders

More Excluded Benefits

Infertility Treatment
Long-Term/Custodial Nursing Home Care
Bariatric Surgery
Cosmetic Surgery
Chiropractic Care
Hearing Aids
Routine Foot Care
Acupuncture
Weight Loss Programs
Abortion for Which Public Funding is Prohibited
Treatment for Temporomandibular Joint Disorders

+ See All Coverage Details

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Deductible

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Value Expanded Bronze 4800 Copay Plan - no deductible for one urgent care and all PCP visits

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Utah Imaging Centers Llc

Med Expanded Bronze 4800 Copay Plan - no deductible for one urgent care and all PCP visits

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Benefits & Coverage

Costs for Medical Care

Prescription drug coverage

Access to doctors and hospitals

Hospital services

Maternity

Mental Health

Vision Coverage

Exclusions and Limitations

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