Select Health Med Gold 1000 - no deductible for office visits
SelectHealth
Plan overview
Medical deductible
Individual: $0
Family: $0
Per Person: $0
Prescription drug deductible
Individual: $500
Family: $0
Per Person: $500
Combined medical and drug out of pocket maximum
Individual: $9900
Family: $19800
Per Person: $9900
Office visit
Primary Doctor
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Specialist
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: Not Applicable
CoInsurance: 25% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 50% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Generic drugs
CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
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
Limit Quantity:
Limit Unit:
Benefit Explanation:
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 20% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 20% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: $400.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Urgent care facility
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 20% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 20% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit: Visit(s) per Year
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).