Med Benchmark Silver 6000 Medical Deductible w/Vision - 68781UT0210001 Health Insurance Plan
SelectHealth health insurance plan with the Plan ID 68781UT0210001. The plan is called Med Benchmark Silver 6000 Medical Deductible w/Vision.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.00% (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 30.00% 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 | 68781UT0210001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | SelectHealth | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Health Insurance Plan Variant | 68781UT0210001-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 13 May 2025 06:05 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 68781UT0210001-00 Standard On Exchange Plan - 68781UT0210001-01 Open to Indians below 300% FPL - 68781UT0210001-02 Open to Indians above 300% FPL - 68781UT0210001-03 73% AV Silver Plan - 68781UT0210001-04 |
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| Last Plan Update Date | Wed, 23 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 13 May 2025 06:05 GMT |
Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan Variant 68781UT0210001-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.700033586228891 |
| 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 | Standard Silver Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $2475 per group |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $825 per person |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $825 |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| 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, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9975 |
| First Tier Utilization | 100% |
| Formulary ID | UTF016 |
| Formulary URL | URL |
| HIOS Product ID | 68781UT021 |
| 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 | New |
| 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 | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $12000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $6000 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $6,000 |
| 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 | UTN001 |
| 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 Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 68781UT0210001-00 |
| 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 | Med Benchmark Silver 6000 Medical Deductible w/Vision |
| Plan Type | HMO |
| Plan Variant Marketing Name | Med Benchmark Silver 6000 Medical Deductible w/Vision |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,900 |
| SBC Scenario, Having a Baby, Copayment | $700 |
| SBC Scenario, Having a Baby, Deductible | $6,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $400 |
| SBC Scenario, Having Diabetes, Deductible | $800 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS001 |
| Source Name | SERFF |
| Plan ID | 68781UT0210001 |
| 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 | $17200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,600 |
| 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 |
| Wellness Program Offered | No |
Copay & Coinsurance of Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan, 68781UT0210001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Med Benchmark Silver 6000 Medical Deductible w/Vision, 68781UT0210001 Health Insurance Plan, 68781UT0210001
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Does Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan, 68781UT0210001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (68781UT0210001) Health Insurance Plan, Variant (68781UT0210001-00) offer Disease Management Programs?
Does (68781UT0210001) Health Insurance Plan, Variant (68781UT0210001-00) have Out Of Country Coverage?
Does (68781UT0210001) Health Insurance Plan, Variant (68781UT0210001-00) have Out of Service Area Coverage?
Does (68781UT0210001) Health Insurance Plan, Variant (68781UT0210001-00) offer Disease Management Programs?
Does Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan, Variant (68781UT0210001-00) offer Disease Management Programs for Asthma?
Does Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan, Variant (68781UT0210001-00) offer Disease Management Programs for Heart disease?
Does Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan, Variant (68781UT0210001-00) offer Disease Management Programs for Depression?
Does Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan, Variant (68781UT0210001-00) offer Disease Management Programs for Diabetes?
Does Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan, Variant (68781UT0210001-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan, Variant (68781UT0210001-00) offer Disease Management Programs for Low back pain?
Does Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan, Variant (68781UT0210001-00) offer Disease Management Programs for Pregnancy?
Does Med Benchmark Silver 6000 Medical Deductible w/Vision Health Insurance Plan, Variant (68781UT0210001-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 13 May 2025 06:05 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