SelectHealth

Select Health Monument Value Gold $0 Medical Deductible

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Summary Of Benefits

Plan Overview

Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,000 Family: $18,000 Per Person: $9,000
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: $20.00 \| Coinsurance: Not Applicable
Specialist	Standard: Copay: $70.00 \| Coinsurance: Not Applicable

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 25.00% Coinsurance after deductible
Non Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 50.00% Coinsurance after deductible
Generic Drugs	Standard: Copay: $10.00 \| Coinsurance: Not Applicable
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 50.00% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: Copay: Not Applicable \| Coinsurance: 30.00%
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: 30.00%

Emergency and Urgent Care

Emergency Room

Standard: Copay: Not Applicable | Coinsurance: 30.00%