Select Health Value Silver $1500 Medical Deductible Off Exchange – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $90 copay
Urgent care visit: $45 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | Success
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| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $90 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $45 copay |
| Emergency room | $1,500 copay |
| Ambulance | $175 copay |
| Hospital stay (facility) | first 3 day(s) $3,150 per day then $0 copay after deductible |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | 50% after deductible |
| Outpatient procedure (physician) | 50% after deductible |
| Physical rehabilitation | $25 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 3 day(s) $3,150 per day then $0 copay |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $100 copay after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 50% after deductible |
| Imaging (CT/PET/MRI) | 50% after deductible |
| Blood work | $15 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 50% after deductible |
| Psychiatric hospital stay | first 3 day(s) $3,150 per day then $0 copay after deductible |
