Select Health - SelectHealth Silver Copay Plan
Deductible
Separate Drug Deductible
Out-of-pocket max
Primary Care Visit
$20 Copay
50% Coinsurance after deductible
Specialist Visit
$60 Copay
50% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
$20 Copay
50% Coinsurance after deductible
Preventive Care/Screening/Immunization
No Charge
50% Coinsurance after deductible
Laboratory Outpatient and Professional Services
$50 Copay
50% Coinsurance after deductible
X-rays and Diagnostic Imaging
$50 Copay
50% Coinsurance after deductible
Imaging (CT/PET scans, MRIs)
$475 Copay
50% Coinsurance after deductible
Generic Drugs
$15 Copay
$15 Copay
Preferred Brand Drugs
$100 Copay after deductible
$100 Copay after deductible
Non-Preferred Brand Drugs
25% Coinsurance after deductible
25% Coinsurance after deductible
Specialty Drugs
50% Coinsurance after deductible
50% Coinsurance after deductible
Outpatient Facility Fee
$400 Copay
50% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
$75 Copay
50% Coinsurance after deductible
Emergency Room Services
$1200 Copay
$1200 Copay
Emergency Transportation/Ambulance
$200 Copay
$200 Copay
Urgent Care
$40 Copay
50% Coinsurance after deductible
Inpatient Hospital Services
$1500 Copay per day
50% Coinsurance after deductible
Inpatient Physician and Surgical Services
No Charge
50% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
$20 Copay
50% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
$1500 Copay per day
50% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
$20 Copay
50% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
$1500 Copay per day
50% Coinsurance after deductible
Prenatal and Postnatal Care
$20 Copay
50% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
$1500 Copay
50% Coinsurance after deductible
Home Healthcare Services
$60 Copay
50% Coinsurance after deductible
Outpatient Rehabilitation Services
$60 Copay
50% Coinsurance after deductible
Habilitation Services
$60 Copay
50% Coinsurance after deductible
Skilled Nursing Facility
$1500 Copay per day
50% Coinsurance after deductible
Durable Medical Equipment
40% Coinsurance
50% Coinsurance after deductible
Hospice Services
$60 Copay
50% Coinsurance after deductible
Chiropractic Care
$20 Copay
50% Coinsurance after deductible
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
$60 Copay
50% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
$60 Copay
50% Coinsurance after deductible
Well Baby Visits and Care
No Charge
50% Coinsurance after deductible
Allergy Testing
$60 Copay
50% Coinsurance after deductible
Diabetes Education
No Charge
50% Coinsurance after deductible
Nutritional Counseling
No Charge
50% Coinsurance after deductible
Eye Exam for Children
$60 Copay
50% Coinsurance after deductible
Eye Glasses for Children
$60 Copay
50% Coinsurance after deductible
Accidental Dental
40% Coinsurance
40% Coinsurance
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