Medical Benefits
SelectHealth Med and Value Networks
Annual Deductible( per person / family)
Annual Out-of-Pocket Maximum( per person / family)
Value Network Med Network Out-of-Network In-Network Tier 1 Tier 2
Out-of-Network
$ 1,000 / $ 2,000 $ 1,000 / $ 2,000 $ 2,000 / $ 4,000
$ 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
Retail – 30 day supply 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
MENTAL HEALTH SERVICES
20 % After Deductible
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
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