SelectHealth Select Care Preference Gold 1000 (Utah)

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Company SelectHealth
Plan Year 2014
State Utah
Metal Tier Gold
Plan Type HMO
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Cost Sharing Benefits (In Network)

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.

Deductible (Individual) $1,000
Deductible (Family) $2,500
Coinsurance 20%
Out of Pocket Maximum (Individual) $2,900
Out of Pocket Maximum (Family) $5,800

Doctors Visits

Primary Care Visit $25 Copay after deductible
Specialist Visit $40 Copay after deductible
In Patient Hospital Services 20% Coinsurance after deductible
Emergency Room Services $250 Copay after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 20% coinsurance
Laboratory Outpatient and Professional Services $0
X-ray and Diagnostic Imaging $0


Mental / Behavioral Health 20% coinsurance
Rehabilitative Speech Therapy $40 copay
Rehabilitative Occupational & Physical Therapy $40 copay
Outpatient Facility 20% coinsurance
Outpatient Surgery 20% coinsurance

Prescription Drugs

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.

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