| Benefits | Select Care Transition |
| Deductible, not included in the maximum coinsurance |
$250 individual/$750 family
$500 individual/$1,500 family
$1,000 individual/$2,500 family
$2,500 individual/$5,000 family
|
| Coinsurance/Maximum Coinsurance | 20% coinsurance/$1,000 maximum coinsurance
50% coinsurance/$2,500 maximum coinsurance |
| Emergency Room | Coinsurance after deductible |
| Preventive Care | Not Covered |
| Office Visits | Coinsurance after deductible |
| Intermountain InstaCare/Urgent Care | Coinsurance after deductible |
| Intermountain KidsCare | Coinsurance after deductible |
| Prescription Drugs | Not covered |