Select Health Monument Value Gold $0 Medical Deductible – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $70 copay
Urgent care visit: $70 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | Success
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| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $70 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $70 copay |
| Emergency room | 30% coinsurance |
| Ambulance | 30% coinsurance |
| Hospital stay (facility) | 30% coinsurance |
| Hospital stay (physician) | 30% coinsurance |
| Outpatient procedure (facility) | 30% coinsurance |
| Outpatient procedure (physician) | 30% coinsurance |
| Physical rehabilitation | $25 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | 25% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 5% coinsurance |
| Imaging (CT/PET/MRI) | 30% coinsurance |
| Blood work | $5 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 30% coinsurance |
| Psychiatric hospital stay | 30% coinsurance |
