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SelectHealth, Inc.   -   Med Exp Bronze 9200 Health Deductible - No deductible for office visits

Deductible & Out-of-Pocket
In Network
Out-of-Network
Deductible
Out-of-Pocket max
Doctor Visit
In Network
Out-of-Network
Additional Information
Primary Care Visit
$30 Copay
100% Coinsurance
Specialist Visit
$95 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$30 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Tests
In Network
Out-of-Network
Additional Information
Laboratory Outpatient and Professional Services
$125 Copay
100% Coinsurance
X-rays and Diagnostic Imaging
$125 Copay
100% Coinsurance
Imaging (CT/PET scans, MRIs)
No Charge after deductible
100% Coinsurance
Drugs
In Network
Out-of-Network
Additional Information
Generic Drugs
$40 Copay
100% Coinsurance
Preferred Brand Drugs
No Charge after deductible
100% Coinsurance
Non-Preferred Brand Drugs
No Charge after deductible
100% Coinsurance
Specialty drugs
No Charge after deductible
100% Coinsurance
Outpatient
In Network
Out-of-Network
Additional Information
Outpatient Facility Fee
No Charge after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
No Charge after deductible
100% Coinsurance
Urgent Care
In Network
Out-of-Network
Additional Information
Emergency Room Services
No Charge after deductible
No Charge after deductible
Emergency Transportation/Ambulance
No Charge after deductible
No Charge after deductible
Urgent Care
$45 Copay
100% Coinsurance
Hospital
In Network
Out-of-Network
Additional Information
Inpatient Hospital Services
No Charge after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
No Charge after deductible
100% Coinsurance
Mental / Behavioral Health
In Network
Out-of-Network
Additional Information
Mental/Behavioral Health Outpatient Services
$30 Copay
100% Coinsurance
Mental/Behavioral Health Inpatient Services
No Charge after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$30 Copay
100% Coinsurance
Substance Abuse Disorder Inpatient Services
No Charge after deductible
100% Coinsurance
Pregnancy
In Network
Out-of-Network
Additional Information
Prenatal and postnatal care
$30 Copay
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
No Charge after deductible
100% Coinsurance
Other Special Needs
In Network
Out-of-Network
Additional Information
Home Healthcare Services
$45 Copay
100% Coinsurance
Outpatient Rehabilitation Services
$45 Copay
100% Coinsurance
Habilitation Services
$45 Copay
100% Coinsurance
Skilled Nursing Facility
No Charge after deductible
100% Coinsurance
Durable Medical Equipment
No Charge after deductible
100% Coinsurance
Hospice Services
No Charge after deductible
100% Coinsurance
Chiropractic Care
$45 Copay
100% Coinsurance
Acupuncture
Not Covered
Not Covered
Rehabilitative Speech Therapy
No Charge after deductible
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
No Charge after deductible
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
$95 Copay
100% Coinsurance
Diabetes Education
$30 Copay
100% Coinsurance
Nutritional Counseling
No Charge after deductible
100% Coinsurance
Children's Vision
In Network
Out-of-Network
Additional Information
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge after deductible
100% Coinsurance
Dental
In Network
Out-of-Network
Additional Information
Accidental Dental
No Charge after deductible
No Charge after deductible
Basic Dental Care (Adult)
Not Covered
Not Covered
Basic Dental Care (Child)
Not Covered
Not Covered
Dental Check Up (Child)
Not Covered
Not Covered
Major Dental Care (Adult)
Not Covered
Not Covered
Major Dental Care (Child)
Not Covered
Not Covered
Orthodontia (Adult)
Not Covered
Not Covered
Orthodontia (Child)
Not Covered
Not Covered
Routine Dental Services (Adult)
Not Covered
Not Covered

Carrier Notices

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