Signature Benchmark Gold – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $8,950 per person $17,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | 30% coinsurance |
| Ambulance | 30% coinsurance |
| Hospital stay (facility) | 30% coinsurance |
| Hospital stay (physician) | 30% coinsurance |
| Outpatient procedure (facility) | 30% coinsurance |
| Outpatient procedure (physician) | 30% coinsurance |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | 25% coinsurance after deductible |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge |
| Imaging (CT/PET/MRI) | 30% coinsurance |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 30% coinsurance |
| Psychiatric hospital stay | 30% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://selecthealth.org/files/sbc/I61A0147_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=SHS |
