Signature Benchmark Silver 5900 Medical Deductible – no deductible for office visits – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	Success Your progress has been saved. We have sent an email to with a link to continue your application ×
Out-of-pocket max	$9,000 per person $18,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	No charge
Specialist visit	$40 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay
Emergency room	$600 copay after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	$40 copay after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$25 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	$30 copay
Imaging (CT/PET/MRI)	$350 copay
Blood work	$30 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	50% coinsurance after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://selecthealth.org/files/sbc/I61A0125_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