Value Benchmark Platinum Standardized Plan

68781UT0200038
Platinum
HMO

Value Benchmark Platinum Standardized Plan is a Platinum HMO plan by Select Health.

IMPORTANT: You are viewing the 2024 version of Value Benchmark Platinum Standardized Plan 68781UT0200038. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Value Benchmark Platinum Standardized Plan is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Value Benchmark Platinum Standardized Plan 68781UT0200038.
Insurer: Select Health
Network Type: HMO
Metal Type: Platinum
HSA Eligible?: No
Plan ID: 68781UT0200038

Cost-Sharing Overview

Value Benchmark Platinum Standardized Plan 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 Value Benchmark Platinum 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

Value Benchmark Platinum 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 Value Benchmark Platinum 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

Value Benchmark Platinum 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
$10.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$10.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$150.00 Not ApplicableNot Applicable 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
$150.00 Not ApplicableNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 20.00%Not Applicable 100.00%6.0 Months per 3 Years
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$15.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
Not Applicable 20.00%Not Applicable 100.00%30.0 Visit(s) per Year
Emergency Room Services
Covered
$100.00 Not Applicable$100.00 Not Applicable
Emergency Transportation/Ambulance
Covered
Not Applicable 20.00%Not Applicable 20.00%
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$350.00 Copay per Stay Not ApplicableNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 20.00%Not Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
$150.00 Copay per Stay Not ApplicableNot Applicable 100.00%30.0 Days per Year
Prenatal and Postnatal Care
Covered
Not Applicable 20.00%Not Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 20.00%Not Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$10.00 Not ApplicableNot Applicable 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
$350.00 Copay per Stay Not ApplicableNot Applicable 100.00% Certain limitations and exclusions exist. Refer to the plan materials for more information.
Substance Abuse Disorder Outpatient Services
Covered
$10.00 Not ApplicableNot Applicable 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
$350.00 Copay per Stay Not ApplicableNot Applicable 100.00% Certain limitations and exclusions exist. Refer to the plan materials for more information.
Generic Drugs
Covered
$5.00 Not Applicable$5.00 Not Applicable Certain generic and brand name drugs have lower cost sharing than the generic tier
Preferred Brand Drugs
Covered
$10.00 Not Applicable$10.00 Not Applicable
Non-Preferred Brand Drugs
Covered
$50.00 Not Applicable$50.00 Not Applicable
Specialty Drugs
Covered
$150.00 Not Applicable$150.00 Not Applicable
Outpatient Rehabilitation Services
Covered
$35.00 Not ApplicableNot Applicable 100.00%20.0 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
$35.00 Not ApplicableNot Applicable 100.00%20.0 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
Not Applicable 20.00%Not Applicable 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
$100.00 Not ApplicableNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge No ChargeNot Applicable 100.00%1.0 Visit(s) per Year
Eye Glasses for Children
Covered
Not Applicable 20.00%Not Applicable 100.00%1.0 Item(s) per Year Frames are not covered
Dental Check-Up for Children
Covered
Not Applicable 100.00%Not Applicable 100.00%
Rehabilitative Speech Therapy
Covered
$10.00 Not ApplicableNot Applicable 100.00%30.0 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 30 days.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$10.00 Not ApplicableNot Applicable 100.00%30.0 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 30 days.
Well Baby Visits and Care
Covered
No Charge No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
$30.00 Not ApplicableNot Applicable 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
Not Applicable 20.00%Not Applicable 100.00% Covered only in limited circumstances
Accidental Dental
Not Covered
Dialysis
Covered
Not Applicable 20.00%Not Applicable 100.00%
Allergy Testing
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Radiation
Covered
Not Applicable 20.00%Not Applicable 100.00%
Diabetes Education
Covered
Not Applicable 20.00%Not Applicable 100.00%
Prosthetic Devices
Not Covered
Infusion Therapy
Covered
Not Applicable 20.00%Not Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
Not Applicable 20.00%Not Applicable 100.00% Covered only in limited circumstances
Gender Affirming Care
Not Covered
Inherited Metabolic Disorder – PKU
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Autism Spectrum Disorders
Covered
Not Applicable 20.00%Not Applicable 100.00% Covered as required by state law.

Free Preventive Services

There is no copayment or coinsurance for any of the following Value Benchmark Platinum 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.

Additional Resources

Below are additional resources for Value Benchmark Platinum 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 Value Benchmark Platinum 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

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