Select Health SLHN Silver 4500

SelectHealth, Inc. · 2027 plan year

Silver
Ind. medical deductible
$3,600
Rx deductible (separate)
$1,500
Family deductible
$7,200
Ind. OOP max
$8,900
Family OOP max
$17,800

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

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Live premium estimate

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Benefits & cost sharing

Primary Care

BenefitIn-network
Preventive Care/Screening/ImmunizationNo charge
Primary Care Visit to Treat an Injury or Illness$15.00

Specialist

BenefitIn-network
Specialist Visit$50.00

Hospital

BenefitIn-network
Emergency Room Services$350.00 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)40.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services40.00% Coinsurance after deductible
Urgent Care Centers or Facilities$50.00

Pharmacy

BenefitIn-network
Generic Drugs$25.00
Non-Preferred Brand Drugs50% Coinsurance after deductible
Preferred Brand Drugs25% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance after deductible

Mental Health

BenefitIn-network
Mental/Behavioral Health Inpatient Services40.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services$15.00

Other

BenefitIn-network
Diabetes EducationNo charge
Dialysis40.00% Coinsurance after deductible
Accidental Dental40.00% Coinsurance after deductible
Allergy Testing$50.00
Chemotherapy50.00% Coinsurance after deductible
Chiropractic Care$20.00
Delivery and All Inpatient Services for Maternity Care40.00% Coinsurance after deductible
Durable Medical Equipment40.00% Coinsurance after deductible
Emergency Transportation/Ambulance40.00% Coinsurance after deductible
Eye Glasses for Children40.00% Coinsurance after deductible
Habilitation Services$50.00
Home Health Care Services40.00% Coinsurance after deductible
Hospice Services40.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)40.00% Coinsurance after deductible
Infusion Therapy40.00% Coinsurance after deductible
Inpatient Physician and Surgical Services40.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services$60.00
Nutritional CounselingNo charge
Other Practitioner Office Visit (Nurse, Physician Assistant)$15.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)40.00% Coinsurance after deductible
Outpatient Rehabilitation Services$30.00
Prenatal and Postnatal Care40.00% Coinsurance after deductible
Prosthetic Devices40.00% Coinsurance after deductible
Radiation40.00% Coinsurance after deductible
Reconstructive Surgery40.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy$50.00 Copay after deductible
Rehabilitative Speech Therapy$50.00 Copay after deductible
Routine Eye Exam for Children$50.00
Skilled Nursing Facility40.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services40.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services$15.00
Transplant40.00% Coinsurance after deductible
Well Baby Visits and CareNo charge
X-rays and Diagnostic Imaging$60.00

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