Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits

68781UT0020043
Expanded Bronze
HMO

Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits is an Expanded Bronze HMO plan by SelectHealth.

IMPORTANT: You are viewing the 2023 version of Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits 68781UT0020043. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits 68781UT0020043.
Insurer: SelectHealth
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 68781UT0020043

Cost-Sharing Overview

Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Med Expanded Bronze 5900 Copay Plan - no deductible for all office visits?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan 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.
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits covers when you are out of the service area or out of the country.

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
National Network: No

Additional Benefits and Cost-Sharing

Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$50.00 100.00%
Specialist Visit
Covered
$90.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$50.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 100.00% A procedure in a Freestanding Ambulatory Surgery Center, will cost the member less than the amount shown for other outpatient facilities.
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
50.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
50.00% Coinsurance after deductible 100.00%
Routine Eye Exam (Adult)
Covered
No Charge No Charge 100.00%1 Visit(s) per Year
Urgent Care Centers or Facilities
Covered
$70.00 100.00%
Home Health Care Services
Covered
50.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
$600.00 Copay after deductible $600.00 Copay after deductible
Emergency Transportation/Ambulance
Covered
$300 Copay after deductible $300 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$650.00 Copay per Day after deductible 100.00% No benefits are paid until the deductible is met. Member responsibility is on a per-day basis up to 5 days.
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
$650.00 Copay per Day after deductible 100.00%60 Days per Year No benefits are paid until the deductible is met. Member responsibility is on a per-day basis up to 5 days.
Prenatal and Postnatal Care
Covered
50.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
$650.00 Copay after deductible 100.00% Member responsibility is on a per-day basis up to 5 days.
Mental/Behavioral Health Outpatient Services
Covered
50.00% Coinsurance after deductible 100.00% Certain limitations and exclusions exist. Refer to the plan materials for more information. Office visits for Mental/Behavioral Health Outpatient Services: please refer to the Primary Care Visit for cost sharing information
Mental/Behavioral Health Inpatient Services
Covered
$650.00 Copay per Day after deductible 100.00% Certain limitations and exclusions exist. Refer to the plan materials for more information. Member responsibility is on a per-day basis up to 5 days.
Substance Abuse Disorder Outpatient Services
Covered
50.00% Coinsurance after deductible 100.00% Certain limitations and exclusions exist. Refer to the plan materials for more information. Office visits for Mental/Behavioral Health Outpatient Services: please refer to the Primary Care Visit for cost sharing information
Substance Abuse Disorder Inpatient Services
Covered
$650.00 Copay per Day after deductible 100.00% Certain limitations and exclusions exist. Refer to the plan materials for more information. Member responsibility is on a per-day basis up to 5 days.
Generic Drugs
Covered
$30.00 $30.00 Certain generic and brand name drugs have lower cost sharing than the generic tier
Preferred Brand Drugs
Covered
$55.00 Copay after deductible $55.00 Copay after deductible
Non-Preferred Brand Drugs
Covered
$70.00 Copay after deductible $70.00 Copay after deductible
Specialty Drugs
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Outpatient Rehabilitation Services
Covered
$50.00 100.00%20 Visit(s) per Year Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have a combined limit of 40 days.
Habilitation Services
Covered
$50.00 100.00%20 Visit(s) per Year Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits.
Chiropractic Care
Not Covered
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 100.00% Certain limitations and exclusions exist. Refer to the plan materials for more information.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
$150 Copay after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No Charge 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge No Charge 100.00%1 Visit(s) per Year
Eye Glasses for Children
Covered
50.00% Coinsurance after deductible 100.00%1 Item(s) per Year Frames are not covered
Dental Check-Up for Children
Covered
$90.00 100.00%2 Visit(s) per Year
Rehabilitative Speech Therapy
Covered
$90.00 Copay after deductible 100.00%40 Days per Year Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have a combined limit of 40 days. Inpatient member responsibility is on a per-day basis, up to 5 days.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$90.00 Copay after deductible 100.00%40 Days per Year Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have a combined limit of 40 days. Inpatient member responsibility is on a per-day basis, up to 5 days.
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
$650.00 Copay after deductible 100.00% Covered only in limited circumstances Member responsibility is on a per-day basis up to 5 days.
Accidental Dental
Covered
50.00% Coinsurance after deductible 100.00% Covered only in limited circumstances Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
Dialysis
Covered
50.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
$90.00 100.00%
Chemotherapy
Covered
30.00% Coinsurance after deductible 100.00%
Radiation
Covered
50.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
50.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
50.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
50.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
50.00% Coinsurance after deductible 100.00%
Reconstructive Surgery
Covered
$650.00 Copay after deductible 100.00% Covered only in limited circumstances Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
Gender Affirming Care
Covered
50.00% Coinsurance after deductible 100.00%
Inherited Metabolic Disorder – PKU
Covered
$90.00 100.00%
Autism Spectrum Disorders
Covered
50.00% Coinsurance after deductible 100.00% Covered as required by state law.

Free Preventive Services

There is no copayment or coinsurance for any of the following Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Med Expanded Bronze 5900 Copay Plan – no deductible for all office visits including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Med Expanded Bronze 5900 Copay Plan - no deductible for all office visits?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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