SelectHealth

Select Health Value Silver $3200 Medical Deductible

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $3,200 Family: $6,400 Per Person: $3,200
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,200 Family: $18,400 Per Person: $9,200
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: $35.00 \| Coinsurance: Not Applicable
Specialist	Standard: Copay: $50.00 \| 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: $15.00 \| Coinsurance: Not Applicable
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 50.00% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: Copay: Not Applicable \| Coinsurance: 40.00% Coinsurance after deductible
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: 40.00% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: Copay: $600.00 Copay after deductible | Coinsurance: Not Applicable