SelectHealth

Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $1,750 Family: $3,500 Per Person: $1,750
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,050 Family: $16,100 Per Person: $8,050
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: No Charge after deductible \| Coinsurance: Not Applicable
Specialist	Standard: Copay: No Charge after deductible \| Coinsurance: Not Applicable

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible
Non Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 50.00% Coinsurance after deductible
Generic Drugs	Standard: Copay: No Charge after deductible \| Coinsurance: Not Applicable
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 50.00% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: Copay: Not Applicable \| Coinsurance: 10.00% Coinsurance after deductible
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: 10.00% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: Copay: Not Applicable | Coinsurance: 10.00% Coinsurance after deductible