SelectHealth

Select Health Monument Value Silver $1500 Medical Deductible

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $1,500 Family: $3,000 Per Person: $1,500
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: $30.00 \| Coinsurance: Not Applicable
Specialist	Standard: Copay: $80.00 \| Coinsurance: Not Applicable

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: $100.00 Copay after deductible \| Coinsurance: Not Applicable
Non Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 50.00% Coinsurance after deductible
Generic Drugs	Standard: Copay: $15.00 \| Coinsurance: Not Applicable
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 50.00% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: Copay: $3150.00 Copay per Day after deductible \| Coinsurance: Not Applicable
Inpatient Services	Standard: Copay: No Charge \| Coinsurance: No Charge

Emergency and Urgent Care

Emergency Room

Standard: Copay: $1,500.00 | Coinsurance: Not Applicable