SimpliveraCoverage Companion

Select Health Monument Value Gold $1500 Medical Deductible

SelectHealth, Inc. · 2027 plan year

Gold
Ind. medical deductible
$1,500
Rx deductible (separate)
$900
Family deductible
$3,000
Ind. OOP max
$9,500
Family OOP max
$19,000

This plan sets a separate deductible for prescription drugs. The medical deductible shown does not cover prescriptions; they have their own.

Other cost-sharing reduction variants for this plan:

Standard Gold Off Exchange PlanStandard Gold On Exchange PlanZero Cost Sharing Plan Variation

More SelectHealth, Inc. plans in CO

Select Health Value Colorado Option Bronze HSA EligibleSelect Health Monument Value Colorado Option Bronze HSA EligibleSelect Health Value Bronze $6900 Medical Deductible HSA EligibleSelect Health Monument Value Bronze $6900 Medical Deductible HSA EligibleSelect Health Value Bronze $8500 Medical Deductible HSA Eligible

Live premium estimate

$

Benefits & cost sharing

Primary Care

BenefitIn-network
Preventive Care/Screening/ImmunizationNo charge
Primary Care Visit to Treat an Injury or Illness$20.00

Specialist

BenefitIn-network
Specialist Visit$50.00

Hospital

BenefitIn-network
Urgent Care Centers or Facilities$40.00
Emergency Room Services25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)25.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services25.00% Coinsurance after deductible

Pharmacy

BenefitIn-network
Generic Drugs$10.00
Medical Service Drugs50.00% Coinsurance after deductible
Non-Preferred Brand Drugs50.00% Coinsurance after deductible
Non-Preferred Generic Drugs$25.00
Preferred Brand Drugs25.00% Coinsurance after deductible
Preventive DrugsNo charge
Specialty Drugs50.00% Coinsurance after deductible

Mental Health

BenefitIn-network
Substance Use Disorder Prenatal Care$20.00
Telehealth Mental/Behavioral Health$20.00
Telehealth Substance Use Disorder$20.00
Intensive Outpatient for Mental/Behavioral Health25.00% Coinsurance after deductible
Intensive Outpatient for Substance Use Disorder25.00% Coinsurance after deductible
Mental Health Wellness VisitNo charge
Mental/Behavioral Health Inpatient Services25.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services$50.00
Mental/Behavioral Health Prenatal Care$20.00
Office Visit - Mental/Behavioral Health$50.00
Office Visit - Substance Use Disorder$50.00
Partial Hospitalization for Mental/Behavioral Health25.00% Coinsurance after deductible
Partial Hospitalization for Substance Use Disorder25.00% Coinsurance after deductible
Postpartum Mental/Behavioral Health$20.00
Postpartum Substance Use Disorder$20.00
Residential Day Treatment for Mental/Behavioral Health25.00% Coinsurance after deductible
Residential Day Treatment for Substance Use Disorder25.00% Coinsurance after deductible

Other

BenefitIn-network
Standalone Laboratory$10.00
Substance Abuse Disorder Inpatient Services25.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services$50.00
Telehealth PCPNo charge
Telehealth Specialist$50.00
Transplant25.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders25.00% Coinsurance after deductible
Well Baby Visits and CareNo charge
X-rays and Diagnostic Imaging5.00% Coinsurance after deductible
Abortion for Which Public Funding is ProhibitedNo charge
Acupuncture$20.00
Allergy Testing$50.00
Applied Behavior Analysis Based TherapiesNo Charge after deductible
Autism Spectrum Disorders - Assessment and Evaluation Services$50.00
Bariatric Surgery25.00% Coinsurance after deductible
Chemotherapy50.00% Coinsurance after deductible
Chiropractic Care$20.00
Delivery and All Inpatient Services for Maternity Care25.00% Coinsurance after deductible
Diabetes Education$50.00
Diabetic Supplies25.00% Coinsurance after deductible
Dialysis$50.00
Durable Medical Equipment25.00% Coinsurance after deductible
Emergency Transportation/Ambulance25.00% Coinsurance after deductible
Eye Glasses for Children$50.00
Gender Affirming Care25.00% Coinsurance after deductible
Habilitation Services$50.00 Copay after deductible
Hearing Aids25.00% Coinsurance after deductible
Home Health Care Services$50.00
Hospice Services$50.00
Imaging (CT/PET Scans, MRIs)25.00% Coinsurance after deductible
Infertility Treatment25.00% Coinsurance after deductible
Infusion Therapy25.00% Coinsurance after deductible
Inpatient Physician and Surgical Services25.00% Coinsurance after deductible
Inpatient Rehabilitation25.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services$10.00
Nutritional Counseling$50.00
Other Practitioner Office Visit (Nurse, Physician Assistant)$20.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)25.00% Coinsurance after deductible
Outpatient Rehabilitation Services$50.00 Copay after deductible
Prenatal and Postnatal Care$20.00
Private-Duty Nursing$50.00
Prosthetic Devices25.00% Coinsurance after deductible
Prosthetics: Legs and Arms20.00%
Prosthetics: Recreational25.00% Coinsurance after deductible
Radiation25.00% Coinsurance after deductible
Reconstructive Surgery25.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy$50.00 Copay after deductible
Rehabilitative Occupational Therapy$50.00 Copay after deductible
Rehabilitative Physical Therapy$50.00 Copay after deductible
Rehabilitative Speech Therapy$50.00 Copay after deductible
Routine Eye Exam for ChildrenNo charge
Skilled Nursing Facility25.00% Coinsurance after deductible

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