Value Benchmark Expanded Bronze Select Copay Plan - 68781UT0200009 Health Insurance Plan
SelectHealth health insurance plan with the Plan ID 68781UT0200009. The plan is called Value Benchmark Expanded Bronze Select Copay Plan.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.61% (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 35.39% 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 | 68781UT0200009 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | SelectHealth | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Health Insurance Plan Variant | 68781UT0200009-00 | ||||||||||||||||||
| 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 - 68781UT0200009-00 Standard On Exchange Plan - 68781UT0200009-01 |
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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 |
Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan Variant 68781UT0200009-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.6460880966071949 |
| 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 Bronze Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $7000 per group |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $3500 per person |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $3,500 |
| 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 | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | UTF018 |
| 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 | 3 |
| 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 | 50.00% |
| 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 | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | UTN002 |
| 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) | 68781UT0200009-00 |
| 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 | Value Benchmark Expanded Bronze Select Copay Plan |
| Plan Type | HMO |
| Plan Variant Marketing Name | Value Benchmark Expanded Bronze Select Copay Plan |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $6,500 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,800 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS002 |
| Source Name | SERFF |
| Plan ID | 68781UT0200009 |
| 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 | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| 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 Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan, 68781UT0200009
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Value Benchmark Expanded Bronze Select Copay Plan, 68781UT0200009 Health Insurance Plan, 68781UT0200009
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Does Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan, 68781UT0200009 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (68781UT0200009) Health Insurance Plan, Variant (68781UT0200009-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does (68781UT0200009) Health Insurance Plan, Variant (68781UT0200009-00) 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 (68781UT0200009) Health Insurance Plan, Variant (68781UT0200009-00) 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 (68781UT0200009) Health Insurance Plan, Variant (68781UT0200009-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan, Variant (68781UT0200009-00) offer Disease Management Programs for Asthma?
Yes, the Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan Variant
68781UT0200009-00 offers Disease
Management Program for Asthma.
Does Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan, Variant (68781UT0200009-00) offer Disease Management Programs for Heart disease?
Yes, the Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan Variant
68781UT0200009-00 offers Disease
Management Program for Heart disease.
Does Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan, Variant (68781UT0200009-00) offer Disease Management Programs for Depression?
Yes, the Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan Variant
68781UT0200009-00 offers Disease
Management Program for Depression.
Does Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan, Variant (68781UT0200009-00) offer Disease Management Programs for Diabetes?
Yes, the Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan Variant
68781UT0200009-00 offers Disease
Management Program for Diabetes.
Does Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan, Variant (68781UT0200009-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan Variant
68781UT0200009-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan, Variant (68781UT0200009-00) offer Disease Management Programs for Low back pain?
Yes, the Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan Variant
68781UT0200009-00 offers Disease
Management Program for Low back pain.
Does Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan, Variant (68781UT0200009-00) offer Disease Management Programs for Pregnancy?
Yes, the Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan Variant
68781UT0200009-00 offers Disease
Management Program for Pregnancy.
Does Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan, Variant (68781UT0200009-00) offer Disease Management Programs for Weight loss programs?
Yes, the Value Benchmark Expanded Bronze Select Copay Plan Health Insurance Plan Variant
68781UT0200009-00 offers Disease
Management Program 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