SelectHealth

Select Health Med Silver Copay Plan

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $0 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $3,500 Family: not applicable Per Person: $3500
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,000 Family: $18000 Per Person: $9000

Office Visit

Primary Doctor	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $100.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible 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: $1500.00 Copay per Day CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Member responsibility is on a per-day basis up to 3 days.
Inpatient Services	CoPay: No Charge CoInsurance: No Charge Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $1,200.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $1,500.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.
Pre and Postnatal Office Visit	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: $60.00
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