Select $5,800 – 40%

38166WI0180027
Silver
EPO

Select $5,800 – 40% is a Silver EPO plan by Security Health Plan.

IMPORTANT: You are viewing the 2023 version of Select $5,800 – 40% 38166WI0180027. You can enroll in this plan during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

Locations

Select $5,800 – 40% is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Select $5,800 – 40% 38166WI0180027.
Insurer: Security Health Plan
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 38166WI0180027

Cost-Sharing Overview

Select $5,800 – 40% offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Select $5,800 - 40%?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Select $5,800 – 40% offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: Yes
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Select $5,800 – 40% covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Urgent and Emergent Care only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Urgent and Emergent Care only
National Network: No

Additional Benefits and Cost-Sharing

Select $5,800 – 40% includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 100.00%
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00% Limitations include: financial or legal counseling, including estate planning or drafting of a will, homemaker or caretaker services that are not solely related to the member?s care including, but not limited to, sitter or companion services for the member or the member?s family, transportation, house cleaning, or physical maintenance of the house and pastoral counseling or funeral arrangements.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 $60.00 Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home.
Home Health Care Services
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%60 Visit(s) per Year Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.
Emergency Room Services
Covered
No Charge after deductible 40.00% Coinsurance after deductibleNo Charge after deductible 40.00% Coinsurance after deductible Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home.
Emergency Transportation/Ambulance
Covered
No Charge after deductible 40.00% Coinsurance after deductibleNo Charge after deductible 40.00% Coinsurance after deductible Limitations include: Ambulance transport to a home or outpatient setting, medical van transportation, non-emergency licensed professional ambulance services (unless authorized by Security Health Plan), first responders and rescue services and transportation from an acute facility to a sub-acute setting.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 100.00%30 Days per Stay Limitations include: skilled nursing care and/or skilled therapy not prior approved by Security Health Plan and leave-of-absence days, respite care, custodial care, care exceeding the number of days shown in the member?s Schedule of Benefits.
Prenatal and Postnatal Care
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00% Limitations include: prenatal cradle (maternity belt), home delivery and home visits, services performed by a licensed midwife or certified professional midwife, services to determine gender, abortion procedures to end a pregnancy except as specifically stated above.
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$20.00 100.00% Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.
Preferred Brand Drugs
Covered
$40.00 100.00% Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00% Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00% Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.
Outpatient Rehabilitation Services
Covered
$40.00 100.00%20 Visit(s) per Year Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders. Rehabilitative services must be short term.
Habilitation Services
Covered
$40.00 100.00%20 Visit(s) per Year Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders. Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Chiropractic Care
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Durable Medical Equipment
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00% Limitations include: routine maintenance and replacement of equipment because of abuse and neglect and urable medical equipment and medical supplies for your comfort, personal hygiene, convenience or athletics-related conditions including, but not limited to, air conditioners, air cleaners, humidifiers, physical fitness equipment, disposable supplies, self-help devices not medical in nature, duplicate pieces of equipment, deluxe/nonstandard equipment and back-up equipment.
Hearing Aids
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No Charge 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge No Charge 100.00%1 Visit(s) per Year
Eye Glasses for Children
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%1 Item(s) per Year Limited to a selection of glasses approved by Security Health Plan
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 100.00%20 Visit(s) per Year Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders. Rehabilitative services must be short term.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 100.00%20 Visit(s) per Year Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders. Rehabilitative services must be short term.
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00% Limitations include: lodging expenses including meals, expenses related to the recipient?s transportation except for medically necessary professionally licensed ambulance services, the purchase price of any bone marrow, organ or tissue that is sold rather than donated, services not ordered by a physician or surgeon, transplants involving non-human or artificial organs or
Accidental Dental
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Dialysis
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Allergy Testing
Not Covered
Chemotherapy
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00% Intravenous chemotherapy is covered.
Radiation
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
No Charge after deductible 40.00% Coinsurance after deductible
Infusion Therapy
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%4 Visit(s) per Year Limitations include: cosmetic or elective orthodontic care, periodontal care, general dental care, upper and lower jawbone surgery except as required for direct treatment of acute traumatic injury, dislocation, cancer or temporomandibular joint disorder and orthognathic surgery jaw alignment, except as a treatment of obstructive sleep apnea.
Nutritional Counseling
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00% Covered only when both of the following are true: nutritional education is required for a disease in which patient self-management is an important component of the treatment and there exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional
Reconstructive Surgery
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Not Covered
Services covered only Hormone Therapy and Genital reconstructive surgery
Autism Spectrum Disorders
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Cardiac Rehabilitation
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%36 Visit(s) per Year
Clinical Trials
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Diabetes Care Management
Not Covered
Dental Anesthesia
Covered
No Charge after deductible 40.00% Coinsurance after deductible 100.00%
Mental Health Other
Not Covered
Prescription Drugs Other
Not Covered
Newborn Services Other
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Select $5,800 – 40% preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Select $5,800 – 40% including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Select $5,800 - 40%?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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