Value Benchmark Expanded Bronze Copay Plan – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $45 copay
Specialist visit: $90 copay
Urgent care visit: $70 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $45 copay |
| Specialist visit | $90 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $70 copay |
| Emergency room | $1,500 copay |
| Ambulance | $250 copay |
| Hospital stay (facility) | $2950 copay per Day |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $1,200 copay |
| Outpatient procedure (physician) | $100 copay |
| Physical rehabilitation | $90 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $2,950 copay |
Pharmacy, Drugs, and Medication
| Generic | $30 copay |
| Brand | $125 copay after deductible |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $75 copay |
| Imaging (CT/PET/MRI) | $750 copay |
| Blood work | $75 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $750 copay |
| Psychiatric hospital stay | $2950 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://selecthealth.org/files/sbc/I40A1982_20240101_GGGGGGGG_GGGG_SSSS.pdf |
| Drug and medication plan formulary | https://selecthealth.rxeob.com/mdb_sh/public/router?account=rxc_t5_ut_ds_24 |
| Search doctor list | https://selecthealth.org/find-a-doctor?state=UT&selectHealthPlan=X |
