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Select Health   -   SelectHealth Preference Silver 1500

Deductible & Out-of-Pocket
In Network
Out-of-Network
Deductible
Separate Drug Deductible
Out-of-pocket max
Doctor Visit
In Network
Out-of-Network
Additional Information
Primary Care Visit
$35 Copay after deductible
50% Coinsurance after deductible
Specialist Visit
$60 Copay after deductible
50% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
$35 Copay after deductible
50% Coinsurance after deductible
Preventive Care/Screening/Immunization
No Charge
50% Coinsurance after deductible
Tests
In Network
Out-of-Network
Additional Information
Laboratory Outpatient and Professional Services
No Charge after deductible
50% Coinsurance after deductible
X-rays and Diagnostic Imaging
No Charge after deductible
50% Coinsurance after deductible
Imaging (CT/PET scans, MRIs)
30% Coinsurance after deductible
50% Coinsurance after deductible
Drugs
In Network
Out-of-Network
Additional Information
Generic Drugs
$15.00 Copay
$15.00 Copay
Preferred Brand Drugs
25% Coinsurance after deductible
25% Coinsurance after deductible
Non-Preferred Brand Drugs
40.00% Coinsurance after deductible
40.00% Coinsurance after deductible
Specialty Drugs
40.00% Coinsurance after deductible
40.00% Coinsurance after deductible
Outpatient
In Network
Out-of-Network
Additional Information
Outpatient Facility Fee
30% Coinsurance after deductible
50% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
30% Coinsurance after deductible
50% Coinsurance after deductible
Urgent Care
In Network
Out-of-Network
Additional Information
Emergency Room Services
$300 Copay after deductible
$300 Copay after deductible
Emergency Transportation/Ambulance
30% Coinsurance after deductible
30% Coinsurance after deductible
Urgent Care
$60 Copay after deductible
50% Coinsurance after deductible
Hospital
In Network
Out-of-Network
Additional Information
Inpatient Hospital Services
30% Coinsurance after deductible
50% Coinsurance after deductible
Inpatient Physician and Surgical Services
30% Coinsurance after deductible
50% Coinsurance after deductible
Mental / Behavioral Health
In Network
Out-of-Network
Additional Information
Mental/Behavioral Health Outpatient Services
30% Coinsurance after deductible
50% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
30% Coinsurance after deductible
50% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
30% Coinsurance after deductible
50% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
30% Coinsurance after deductible
50% Coinsurance after deductible
Pregnancy
In Network
Out-of-Network
Additional Information
Prenatal and Postnatal Care
30% Coinsurance after deductible
50% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
30% Coinsurance after deductible
50% Coinsurance after deductible
Other Special Needs
In Network
Out-of-Network
Additional Information
Home Healthcare Services
30% Coinsurance after deductible
50% Coinsurance after deductible
Outpatient Rehabilitation Services
$60 Copay after deductible
50% Coinsurance after deductible
Habilitation Services
$60 Copay after deductible
50% Coinsurance after deductible
Skilled Nursing Facility
30% Coinsurance after deductible
50% Coinsurance after deductible
Durable Medical Equipment
30% Coinsurance after deductible
50% Coinsurance after deductible
Hospice Services
30% Coinsurance after deductible
50% Coinsurance after deductible
Chiropractic Care
50% Coinsurance after deductible
50% Coinsurance after deductible
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
$60 Copay after deductible
50% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
$60 Copay after deductible
50% Coinsurance after deductible
Well Baby Visits and Care
No Charge
50% Coinsurance after deductible
Allergy Testing
$60 Copay after deductible
50% Coinsurance after deductible
Diabetes Education
No Charge
50% Coinsurance after deductible
Nutritional Counseling
No Charge
50% Coinsurance after deductible
Children's Vision
In Network
Out-of-Network
Additional Information
Eye Exam for Children
$60 Copay after deductible
50% Coinsurance after deductible
Eye Glasses for Children
30% Coinsurance after deductible
50% Coinsurance after deductible
Dental
In Network
Out-of-Network
Additional Information
Accidental Dental
30% Coinsurance after deductible
50% Coinsurance after deductible
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
Not covered
Not covered
Dental Check Up (Child)
Not covered
Not covered
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
Not covered
Not covered
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
Not covered
Not covered
Routine Dental Services (Adult)
Not covered
Not covered

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