Select Health SLHP Silver 4500 – no deductible for office visits – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $4,500 per person $4,500 per person |
| Out-of-pocket max | $9,000 per person $18,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $600 copay after deductible |
| Ambulance | $300 copay after deductible |
| Hospital stay (facility) | first 5 day(s) $650 per day then $0 copay after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $650 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | $45 copay after deductible |
| Non-preferred Brand | $55 copay after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge |
| Imaging (CT/PET/MRI) | $150 copay after deductible |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | first 5 day(s) $650 per day then $0 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/b5Uh5czGV7M2Vune8Q8F5ggf.pdf |
