Select Health Monument Value Gold $1500 Medical Deductible – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $40 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | Success
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| Out-of-pocket max | $8,000 per person $16,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | 20% after deductible |
| Ambulance | 20% after deductible |
| Hospital stay (facility) | 20% after deductible |
| Hospital stay (physician) | 20% after deductible |
| Outpatient procedure (facility) | 20% after deductible |
| Outpatient procedure (physician) | 20% after deductible |
| Physical rehabilitation | $25 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 20% after deductible |
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% after deductible |
| Imaging (CT/PET/MRI) | 20% after deductible |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 20% after deductible |
| Psychiatric hospital stay | 20% after deductible |
