Signature Benchmark Gold Standardized Plan
68781UT0200022
Gold
HMO
Signature Benchmark Gold Standardized Plan is a Gold HMO plan by SelectHealth.
IMPORTANT: You are viewing the 2023 version of Signature Benchmark Gold Standardized Plan 68781UT0200022. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Signature Benchmark Gold Standardized Plan is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of Signature Benchmark Gold Standardized Plan 68781UT0200022.
| Insurer: | SelectHealth |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 68781UT0200022 |
Cost-Sharing Overview
Signature Benchmark Gold Standardized Plan offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Signature Benchmark Gold Standardized Plan includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,700.00 | $8700 per person | $17400 per group |
| Deductible: | $2,000.00 | $2000 per person | $4000 per group |
| Coinsurance: | 25.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Signature Benchmark Gold Standardized Plan will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $2,000.00 |
| Copayment: | $10.00 |
| Coinsurance: | $2,600.00 |
| Limit: | $60.00 |
| Deductible: | $900.00 |
| Copayment: | $500.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,000.00 |
| Copayment: | $400.00 |
| Coinsurance: | $20.00 |
| Limit: | $0.00 |
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 Signature Benchmark Gold Standardized Plan?
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
Signature Benchmark Gold Standardized Plan 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 Signature Benchmark Gold Standardized Plan 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
Signature Benchmark Gold Standardized Plan 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 | $30.00 | 100.00% | |
| Specialist Visit Covered | $60.00 | 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $30.00 | 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 25.00% 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 | 25.00% Coinsurance after deductible | 100.00% | |
| Hospice Services Covered | 25.00% Coinsurance after deductible | 100.00% | 6 Months per 3 Years |
| Routine Dental Services (Adult) Not Covered | 100.00% | 100.00% | |
| Infertility Treatment Not Covered | 100.00% | 100.00% | |
| Long-Term/Custodial Nursing Home Care Not Covered | 100.00% | 100.00% | |
| Private-Duty Nursing Not Covered | 100.00% | 100.00% | |
| Routine Eye Exam (Adult) Not Covered | 100.00% | 100.00% | |
| Urgent Care Centers or Facilities Covered | $45.00 | 100.00% | |
| Home Health Care Services Covered | 25.00% Coinsurance after deductible | 100.00% | 30 Visit(s) per Year |
| Emergency Room Services Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | 25.00% Coinsurance after deductible | 100.00% | Member responsibility is on a per-day basis up to 3 days. |
| Inpatient Physician and Surgical Services Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Bariatric Surgery Not Covered | 100.00% | 100.00% | |
| Cosmetic Surgery Not Covered | 100.00% | 100.00% | |
| Skilled Nursing Facility Covered | 25.00% Coinsurance after deductible | 100.00% | 30 Days per Year Member responsibility is on a per-day basis up to 3 days. |
| Prenatal and Postnatal Care Covered | $30.00 | 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | 25.00% Coinsurance after deductible | 100.00% | Member responsibility is on a per-day basis up to 3 days. |
| Mental/Behavioral Health Outpatient Services Covered | $30.00 | 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 | 25.00% Coinsurance 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 3 days. |
| Substance Abuse Disorder Outpatient Services Covered | $30.00 | 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 | 25.00% Coinsurance 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 3 days. |
| Generic Drugs Covered | $15.00 | $15.00 | Certain generic and brand name drugs have lower cost sharing than the generic tier |
| Preferred Brand Drugs Covered | $30.00 | $30.00 | |
| Non-Preferred Brand Drugs Covered | $60.00 | $60.00 | |
| Specialty Drugs Covered | $250.00 | $250.00 | |
| Outpatient Rehabilitation Services Covered | $30.00 | 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 30 days. |
| Habilitation Services Covered | $30.00 | 100.00% | 20 Visit(s) per Year Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. |
| Chiropractic Care Not Covered | 100.00% | 100.00% | |
| Durable Medical Equipment Covered | 25.00% Coinsurance after deductible | 100.00% | Certain limitations and exclusions exist. Refer to the plan materials for more information. |
| Hearing Aids Not Covered | 100.00% | 100.00% | |
| Imaging (CT/PET Scans, MRIs) Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Preventive Care/Screening/Immunization Covered | 0.00% | 100.00% | |
| Routine Foot Care Not Covered | 100.00% | 100.00% | |
| Acupuncture Not Covered | 100.00% | 100.00% | |
| Weight Loss Programs Not Covered | 100.00% | 100.00% | |
| Routine Eye Exam for Children Covered | No Charge No Charge | 100.00% | 1 Visit(s) per Year |
| Eye Glasses for Children Covered | 25.00% Coinsurance after deductible | 100.00% | 1 Item(s) per Year Frames are not covered |
| Dental Check-Up for Children Not Covered | 100.00% | 100.00% | |
| Rehabilitative Speech Therapy Covered | $30.00 | 100.00% | 30 Days per Year Member responsibility is on a per-day basis up to 3 days. 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. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $30.00 | 100.00% | 30 Days per Year Member responsibility is on a per-day basis up to 3 days. 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. |
| Well Baby Visits and Care Covered | No Charge No Charge | 100.00% | |
| Laboratory Outpatient and Professional Services Covered | 25.00% Coinsurance after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Basic Dental Care – Child Not Covered | 100.00% | 100.00% | |
| Orthodontia – Child Not Covered | 100.00% | 100.00% | |
| Major Dental Care – Child Not Covered | 100.00% | 100.00% | |
| Basic Dental Care – Adult Not Covered | 100.00% | 100.00% | |
| Orthodontia – Adult Not Covered | 100.00% | 100.00% | |
| Major Dental Care – Adult Not Covered | 100.00% | 100.00% | |
| Abortion for Which Public Funding is Prohibited Not Covered | 100.00% | 100.00% | |
| Transplant Covered | 25.00% Coinsurance after deductible | 100.00% | Covered only in limited circumstances Member responsibility is on a per-day basis up to 3 days. |
| Accidental Dental Not Covered | 100.00% | 100.00% | |
| Dialysis Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Allergy Testing Covered | $60.00 | 100.00% | |
| Chemotherapy Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Radiation Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Diabetes Education Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Prosthetic Devices Not Covered | 100.00% | 100.00% | |
| Infusion Therapy Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Treatment for Temporomandibular Joint Disorders Not Covered | 100.00% | 100.00% | |
| Nutritional Counseling Not Covered | 100.00% | 100.00% | |
| Reconstructive Surgery Covered | 25.00% Coinsurance after deductible | 100.00% | Covered only in limited circumstances Member responsibility is on a per-day basis up to 3 days. |
| Gender Affirming Care Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Inherited Metabolic Disorder – PKU Covered | $60.00 | 100.00% | |
| Autism Spectrum Disorders Covered | 25.00% 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 Signature Benchmark Gold Standardized Plan 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Signature Benchmark Gold Standardized Plan 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 Signature Benchmark Gold Standardized Plan?
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