Value Expanded Bronze 4800 Copay Plan - no deductible for one u Plan Details for 2020- HealthPocket

Value Expanded Bronze 4800 Copay Plan - no deductible for one u

$341.38/mo

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Zip Code84120
Applicant2/18/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameValue Expanded Bronze 4800 Copay Plan - no deductible for one u
Plan IDhhs-68781UT0020042
Plan Year2020
Insurance ProviderSelectHealth
Metal LevelExpanded Bronze
Plan TypeHMO
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 after deductible
Laboratory Outpatient and Professional ServicesNo Charge after deductible
X-rays and Diagnostic ImagingNo Charge after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$150 Copay after deductible
Deductible - Family$9600 per group
Out-of-Pocket Maximum - Family$15800 per group

Prescription drug coverage

Generic Drugs$25 Copay
Preferred Brand Drugs$55 Copay after deductible
Non-Preferred Brand Drugs$70 Copay after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://selecthealth.org/findaprovider
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?No - Urgent or emergency care only
Does this plan cover services outside the country?No - Urgent or emergency care only

Hospital services

Emergency Room Services$600 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$650 Copay per Day after deductible
Inpatient Physician and Surgical Services40.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service$300 Copay after deductible

Maternity

Prenatal and Postnatal Care40.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care$650 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services40.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services$650 Copay per Day after deductible
Substance use disorder outpatient services40.00% Coinsurance after deductible
Substance use disorder inpatient services$650 Copay per Day after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsIncluded

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Durable Medical Equipment
Hospice Services
Inherited Metabolic Disorder - PKU
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Autism Spectrum Disorders
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Hearing Aids
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Weight Loss Programs
Chiropractic Care
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Treatment for Temporomandibular Joint Disorders
PremiumPlan NameDeductible
from $245
Value Expanded Bronze 4800 Copay Plan - no deductible for one urgent care and all PCP visits
$4,800.00Select
from $277
Med Expanded Bronze 4800 Copay Plan - no deductible for one urgent care and all PCP visits
$4,800.00Select
from $385
Med Expanded Bronze 4800 Copay Plan - no deductible for one urg
$4,800.00Select
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  • Phone Number
    (801) 924-0029
  • Office Locations
    3715 W 4100 S
    West Valley City, UT 84120
3715 W 4100 S West Valley City UT, 84120

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).