Select Health Value Gold $1750 Medical Deductible HSA Qualified – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: No charge after deductible
Specialist visit: No charge after deductible
Urgent care visit: No charge after deductible
Description
Health Care Plan Details
Network type | EPO |
Deductible | Success
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Out-of-pocket max | $8,050 per person $16,100 per family |
Metal tier | Gold |
Visit Copay
Primary care visit | No charge after deductible |
Specialist visit | No charge after deductible |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | No charge after deductible |
Emergency room | 10% after deductible |
Ambulance | 10% after deductible |
Hospital stay (facility) | 10% after deductible |
Hospital stay (physician) | 10% after deductible |
Outpatient procedure (facility) | 10% after deductible |
Outpatient procedure (physician) | 10% after deductible |
Physical rehabilitation | No charge after deductible |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 10% after deductible |
Pharmacy, Drugs, and Medication
Generic | No charge after deductible |
Brand | 20% 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) | 10% after deductible |
Blood work | No charge after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | 10% after deductible |
Psychiatric hospital stay | 10% after deductible |