Select Health Value Colorado Option Gold – EPO

Network type: EPO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $50 copay
Urgent care visit: $50 copay

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Description

Health Care Plan Details

Network type EPO
Deductible $1,700 per person $1,700 per person
Out-of-pocket max $8,700 per person $17,400 per family
Metal tier Gold

Visit Copay

Primary care visit No charge
Specialist visit $50 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
Emergency room 30% after deductible
Ambulance 30% after deductible
Hospital stay (facility) 30% after deductible
Hospital stay (physician) 30% after deductible
Outpatient procedure (facility) 30% after deductible
Outpatient procedure (physician) 30% after deductible
Physical rehabilitation 30% after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay 30% after deductible

Pharmacy, Drugs, and Medication

Generic $10 copay
Brand $50 copay
Non-preferred Brand $200 copay
Specialty $600 copay

Lab Tests and Diagnostic Procedures

X-rays 30% after deductible
Imaging (CT/PET/MRI) 30% after deductible
Blood work 30% after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services 30% after deductible
Psychiatric hospital stay 30% after deductible

Health Plan Provider Information