SelectHealth

BrightPath Silver 4500 - no deductible for office visits

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $4,500 Family: $9000 Per Person: $4500
Prescription Drug Deductible	Individual: $2,500 Family: not applicable Per Person: $2500
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,000 Family: $18000 Per Person: $9000

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $45.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $55.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Certain generic and brand name drugs have lower cost sharing than the generic tier.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $650.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $600.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $650.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Member responsibility is on a per-day basis up to 5 days.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered