Select Health SLHN Silver Copay Plan
SelectHealth, Inc. · 2027 plan year
Silver
- Ind. deductible
- No deductible
- Family deductible
- $0
- Ind. OOP max
- $3,300
- Family OOP max
- $6,600
Other cost-sharing reduction variants for this plan:
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Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Preventive Care/Screening/Immunization | No charge |
| Primary Care Visit to Treat an Injury or Illness | $5.00 |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $30.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | $150.00 |
| Inpatient Hospital Services (e.g., Hospital Stay) | $450.00 Copay per Day |
| Outpatient Surgery Physician/Surgical Services | $15.00 |
| Urgent Care Centers or Facilities | $30.00 |
Pharmacy
| Benefit | In-network |
|---|---|
| Specialty Drugs | 20.00% |
| Generic Drugs | $5.00 |
| Non-Preferred Brand Drugs | 5.00% |
| Preferred Brand Drugs | $20.00 |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Inpatient Services | $450.00 Copay per Day |
| Mental/Behavioral Health Outpatient Services | $5.00 |
Other
| Benefit | In-network |
|---|---|
| Accidental Dental | 10.00% |
| Allergy Testing | $15.00 |
| Chemotherapy | 20.00% |
| Chiropractic Care | No charge |
| Delivery and All Inpatient Services for Maternity Care | $450.00 |
| Diabetes Education | No charge |
| Dialysis | $15.00 |
| Durable Medical Equipment | 10.00% |
| Emergency Transportation/Ambulance | $40.00 |
| Eye Glasses for Children | $15.00 |
| Habilitation Services | $15.00 |
| Home Health Care Services | $30.00 |
| Hospice Services | $30.00 |
| Imaging (CT/PET Scans, MRIs) | $125.00 |
| Infusion Therapy | $15.00 |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | No charge |
| Nutritional Counseling | No charge |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $5.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $250.00 |
| Outpatient Rehabilitation Services | $15.00 |
| Prenatal and Postnatal Care | $5.00 |
| Prosthetic Devices | 20.00% |
| Radiation | 10.00% |
| Reconstructive Surgery | $450.00 |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $15.00 |
| Rehabilitative Speech Therapy | $15.00 |
| Routine Eye Exam for Children | $20.00 |
| Skilled Nursing Facility | $450.00 Copay per Day |
| Substance Abuse Disorder Inpatient Services | $450.00 Copay per Day |
| Substance Abuse Disorder Outpatient Services | $5.00 |
| Transplant | $350.00 |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | No charge |
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