SelectHealth

Value Gold 1500 Medical Deductible

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $1,500.00 Family: $3000 Per Person: $1500
Prescription Drug Deductible	Individual: $250.00 Family: $750 Per Person: $250
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,000.00 Family: $16000 Per Person: $8000

Office Visit

Primary Doctor	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 25% Coinsurance after deductible Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50% Coinsurance after deductible Covered: Covered Benefit Explanation: The Hepatitis C Virus (HCV) drugs covered on non-preferred brand tier are eligible to receive a rebate from the drug manufacturer. The member out-of-pocket costs will be applied to the deductible and the maximum out-of-pocket.
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: Not Applicable CoInsurance: 20% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $350 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: $45.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year
Routine Dental Checkups for Adults	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year