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SelectHealth Select Value Benefits 2016–2017 Beneits Enrollment

Participating
Medical Deductible and Out-of-Pocket Individual/Family
Calendar year deductible and out-of-pocket maximum; deductible is included in the out-of-pocket
maximum
Deductible $1,000/$2,500
Out-of-Pocket Maximum $4,000/$8,000
This amount is your deductible + your maximum
coinsurance and copay
Inpatient Services
Medical, Surgical, Hospice, Emergency Admissions 20% after deductible
Skilled Nursing Facility
Up to 60 days/calendar year
Rehab Therapy: Physical, Speech, Occupational
Up to 40 days/calendar year for all therapy types combined
Professional Services
Office Visits and Office Surgeries
Primary Care Provider (PCP) $25
Secondary Care Provider (SCP) $40
Allergy Tests See office visits
Allergy Treatment and Serum 20%
Physician’s Fees—Medical, Surgical, Anesthesia 20% after deductible
Preventive Services as Outlined by the ACA
Office Visits (PCP/SCP) Covered 100%
Adult and Pediatric Immunizations
Diagnostic Tests: Minor
Other Preventive Services
Outpatient Services
Outpatient Facility And Ambulatory Surgical 20% after deductible
Ambulance (Air Or Ground)—Emergencies Only 20% after deductible
Emergency Room Participating Facility $350 after deductible
Emergency Room Nonparticipating Facility $350 after deductible
Chemotherapy, Radiation, Dialysis 20% after deductible
Diagnostic Tests: Minor Covered 100%
Diagnostic Tests: Major 20% after deductible
Home Health, Hospice, Outpatient Private Nurse 20% after deductible
Outpatient Rehab Therapy: Physical, Speech, Occupational $40 after deductible
Up to 20 visits calendar year for each therapy type

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