Home › Categories › Law & Legal› Summary Of Benefits And Coverages (PDF)

Summary Of Benefits And Coverages (PDF).pdf

SelectHealth-Value-Platinum-Standardized-I40A1947-SBC-Summary-of-Benefits-Coverage.pdf

Preview of Summary of benefits and coverages (PDF)

🔗 Source: skylineinsuranceagency.com

📊 Size: 317 KB

📄 Pages: 8 pages

⬇️ Downloads: 179

Summary

- Coverage Period: 01/01/2023 - 12/31/2023
- Coverage for: Single/Family, Plan Type: HMO
- Network: Using a network provider costs less, out-of-network providers cost the most and may result in balance billing
- Referral: No referral needed to see a specialist
- Out-of-pocket limit: $3,000 person/$6,000 family in-network per calendar year
- Deductible: $0, no deductible for specific services
- Services covered before deductible: No
- Prescription drugs:
- Tier 1: $5/prescription
- Tier 2: $5/prescription
- Tier 3: $10/prescription
- Tier 4: $50/prescription
- Tier 5: $150/prescription
- Common medical events and costs:
- Primary care visit: $10/visit
- Specialist visit: $20/visit
- Diagnostic test: $30/visit
- Imaging: $100/visit
- Childbirth/delivery: 20% co-insurance
- Mental health services: $10/visit for office visits, $150/visit for outpatient
- Hospital stay: $350/visit
- Emergency room services: $100/visit
- Outpatient surgery: $150/visit
- Not covered: dental check-ups, certain services without preauthorization.

Download File

Description

- Coverage Period: 01/01/2023 - 12/31/2023
- Coverage for: Single/Family, Plan Type: HMO
- Network: Using a network provider costs less, out-of-network...

Technical Information

File Format: PDF
File Size: 317 KB
Pages: 8
Language: EN
Total Downloads: 179
Last Updated: 1 week ago

Document Overview

This PDF document about Summary of benefits and coverages (PDF) provides comprehensive information and guidance. Whether you're a beginner or advanced user, this resource offers valuable insights into Summary of benefits and coverages (PDF).