SelectHealth Select Care Preference Gold 1000 UT

Plan Information
Company SelectHealth
State UT
Metal Tier Gold
Plan Type HMO

Cost Sharing Benefits

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $1,000 $0
Deductible (Family) $2,500 $0
Coinsurance 20% $0
Out of Pocket Maximum (Individual) $2,900 $0
Out of Pocket Maximum (Family) $5,800 $0
Services In Network Out of Network
Primary Care Visit $25 Copay after deductible $0
Specialist Visit $40 Copay after deductible $0
In Patient Hospital Services 20% Coinsurance after deductible $0
Emergency Room Services $250 Copay after deductible $250 copay
Mental / Behavioral Health 20% coinsurance $0
Imaging (CT/PET Scans, MRIs) 20% coinsurance $0
Rehabilitative Speech Therapy $40 copay $0
Rehabilitative Occupational & Physical Therapy $40 copay $0
Preventative Care Data Not Available $0
Laboratory Outpatient and Professional Services $0 $0
X-ray and Diagnostic Imaging $0 $0
Outpatient Facility 20% coinsurance $0
Outpatient Surgery 20% coinsurance $0
Prescription Drugs In Network Out of Network
Generic Rx $10
Preferred Brand Rx 25% Coinsurance after deductible
Non Preferred Brand Rx 50% Coinsurance after deductible
Specialty Drugs 20% Coinsurance after deductible

Other Plans

Other plans that are available in the state.

Plan Name
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