Unified Fire Authority Benefit Guide 2026/2027 | Page 7

Medical Benefits
SelectHealth Med and Value Networks
Care and Med Network
In-Network
Out-of-Network Out-of-Network
Annual Deductible( per person / family)
Annual Out-of-Pocket Maximum( per person / family)
Coinsurance
DOCTOR’ S OFFICE
Office Visits( PCP / SCP) Preventive Care
PRESCRIPTION DRUGS
Retail – 30 day supply Tier 1 Tier 2 Tier 3 Tier 4
Retail or Mail Order – 90 day supply Maintenance Tier 1 Maintenance Tier 2 Maintenance Tier 3
HOSPITAL SERVICES
Emergency Room Urgent Care Inpatient Services Outpatient Surgery Ambulance Service
MENTAL HEALTH SERVICES
Office Visits Inpatient Services Outpatient Services
SUBSTANCE ABUSE SERVICES
Office Visits Inpatient Services Outpatient Services
OTHER SERVICES
Maternity Services Home Health Care Outpatient Rehab Therapy: Physical, Speech, Occupational Connect Care
$ 2,000 / $ 4,000
$ 4,000 / $ 8,000
$ 4,000 / $ 8,000
$ 8,000 / $ 16,000
20 % AD
40 %
$ 15 / $ 20 Copay
40 % After Deductible
Covered 100 %
Not Covered
$ 10
$ 25
$ 45
$ 100
$ 10
$ 50
$ 135
$ 75 After Deductible
$ 30 Copay
40 % After Deductible
20 % After Deductible
40 % After Deductible
20 % After Deductible
40 % After Deductible
20 % After Deductible
Covered 100 %
Covered 100 % After Deductible
20 % After Deductible
40 % After Deductible
20 %
40 % After Deductible
Covered 100 %
Covered 100 % After Deductible
20 % After Deductible
40 % After Deductible
20 %
40 % After Deductible
20 % After Deductible
40 % After Deductible
20 % After Deductible
40 % After Deductible
$ 20 After Deductible
40 % After Deductible
Covered 100 %
Not Available
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