Value Network |
Med Network |
Out-of-Network |
||
SelectHealth Med and Value Networks |
Tier 1 |
In-Network |
Tier 2 |
Out-of-Network |
|
Annual Deductible
( per person / family )
|
$ 1,000 /$ 2,000 |
$ 1,000 /$ 2,000 |
$ 2,000 /$ 4,000 |
|
|
Annual Out-of-Pocket Maximum
( per person / family )
|
$ 3,000 /$ 6,000 |
$ 3,000 /$ 6,000 |
$ 6,000 /$ 12,000 |
|
Coinsurance |
20 % AD |
20 % AD |
40 % |
|
|
DOCTOR ’ S OFFICE
Office Visits ( PCP / SCP )
|
$ 15 / $ 20 Copay |
$ 15 / $ 20 Copay |
40 % After Deductible |
|
Preventive Care |
Covered 100 % |
Covered 100 % |
Not Covered |
|
PRESCRIPTION DRUGS |
Tier 1 |
$ 10 |
Tier 2 |
$ 25 |
Tier 3 |
$ 45 |
Tier 4 |
$ 100 |
Retail or Mail Order - 90 day supply | |
Maintenance Tier 1 |
$ 10 |
Maintenance Tier 2 |
$ 50 |
Maintenance Tier 3 |
$ 135 |
HOSPITAL SERVICES | |
Emergency Room |
$ 75 After Deductible |
||
Urgent Care |
$ 30 Copay |
$ 30 Copay |
40 % After Deductible |
Inpatient Services |
20 % After Deductible |
20 % After Deductible |
40 % After Deductible |
Outpatient Surgery |
20 % After Deductible |
20 % After Deductible |
40 % After Deductible |
Ambulance Service |
20 % After Deductible |
||
MENTAL HEALTH SERVICES |
Office Visits |
Covered 100 % |
Covered 100 % |
Covered 100 % After Deductible |
Inpatient Services |
20 % After Deductible |
20 % After Deductible |
40 % After Deductible |
Outpatient Services |
20 % |
20 % |
40 % After Deductible |
SUBSTANCE ABUSE SERVICES |
Office Visits |
Covered 100 % |
Covered 100 % |
Covered 100 % After Deductible |
Inpatient Services |
20 % After Deductible |
20 % After Deductible |
40 % After Deductible |
Outpatient Services |
20 % |
20 % |
40 % After Deductible |
OTHER SERVICES |
Maternity Services |
20 % After Deductible |
20 % After Deductible |
40 % After Deductible |
Home Health Care |
20 % After Deductible |
20 % After Deductible |
40 % After Deductible |
Outpatient Rehab Therapy : Physical , Speech , Occupational |
$ 20 After Deductible |
$ 20 After Deductible |
40 % After Deductible |
Connect Care |
Covered 100 % |
Covered 100 % |
Not Available |