medical · skilled nursing facility4 - up to 60 days per plan year 20% after ... primary care...
TRANSCRIPT
NEBO SCHOOL DISTRICT - SHARE BASE PLAN G1021517 1001 L50A0130 09/01/2018
MEMBER PAYMENT SUMMARY
PARTICIPATING(In-Network)
When using participating providers, you are responsible to pay the amounts in this column. Services from nonparticipating providers are not covered (except emergencies).
CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment - Per Person None
Pre-Existing Conditions (PEC) None
Benefit Accumulator Period plan year
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET5 PARTICIPATING
Self Only Coverage, 1 person enrolled - per plan year
Deductible $2,700
Out-of-Pocket Maximum $3,700
Family Coverage, 2 or more enrolled - per plan year
Deductible - per person/family $2700/$5400
Out-of-Pocket Maximum - per person/family $3700/$7400
(Medical and Pharmacy Included in the Out-of-Pocket Maximum)
INPATIENT SERVICES PARTICIPATING
Medical, Surgical and Hospice4 20% after deductible
Skilled Nursing Facility4 - Up to 60 days per plan year 20% after deductible
Inpatient Rehab Therapy: Physical, Speech, Occupational4
Up to 40 days per plan year for all therapy types combined
PROFESSIONAL SERVICES PARTICIPATING
Office Visits & Minor Office Surgeries
Primary Care Provider (PCP)1
20% after deductible
Secondary Care Provider (SCP)1
20% after deductible
Allergy Tests See Office Visits Above
Allergy Treatment and Serum 20% after deductible
Major Surgery 20% after deductible
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) 20% after deductible
PREVENTIVE SERVICES AS OUTLINED BY THE ACA2,3 PARTICIPATING
Primary Care Provider (PCP)1
Covered 100%
Secondary Care Provider (SCP)1
Covered 100%
Adult and Pediatric Immunizations Covered 100%
Elective Immunizations - herpes zoster (shingles), rotavirus Covered 100%
Diagnostic Tests: Minor Covered 100%
Other Preventive Services
VISION SERVICES PARTICIPATING
Preventive Eye Exams Covered 100%
All Other Eye Exams 20% after deductible
OUTPATIENT SERVICES4 PARTICIPATING
Outpatient Facility and Ambulatory Surgical 20% after deductible
Ambulance (Air or Ground) - Emergencies Only 20% after deductible
Emergency Room - (Participating facility) 20% after deductible
Emergency Room - (Nonparticipating facility) 20% after deductible
Intermountain InstaCare®
Facilities, Urgent Care Facilities 20% after deductible
Intermountain KidsCare®
Facilities 20% after deductible
Intermountain Connect Care®
20% after deductible
Chemotherapy, Radiation and Dialysis 20% after deductible
Diagnostic Tests: Minor2
Covered 100% after deductible
Diagnostic Tests: Major2
20% after deductible
Home Health, Hospice, Outpatient Private Nurse 20% after deductible
Outpatient Rehab Therapy: Physical, Speech, Occupational 20% after deductible
Up to 20 visits per plan year for each therapy type
20% after deductible
Covered 100%
11
NEBO SCHOOL DISTRICT - SHARE BASE PLAN G1021517 1001 L50A0130 09/01/2018MEMBER PAYMENT SUMMARY
PARTICIPATING(In-Network)
MISCELLANEOUS SERVICES PARTICIPATING
Durable Medical Equipment (DME)4
20% after deductible
Miscellaneous Medical Supplies (MMS)3
20% after deductible
Autism Spectrum DisorderApplied behavior analysis and behavioral health services up to $30,000 or600 hours/plan year, whichever is greater
Maternity and Adoption4,6 See Professional, Inpatient or Outpatient
Cochlear Implants4 See Professional, Inpatient or Outpatient
Infertility - Selected Services 50% after deductible (Max Plan Payment $1,500/ plan year; $5,000 lifetime)
Donor Fees for Covered Organ Transplants4
20% after deductible
TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime See Professional, Inpatient or Outpatient
OPTIONAL BENEFITS PARTICIPATING
Mental Health and Chemical Dependency4
Office Visits 20% after deductible
Inpatient 20% after deductible
Outpatient 20% after deductible
Residential Treatment2 20% after deductible
Injectable Drugs and Specialty Medications4 20% after deductible
PRESCRIPTION DRUGS
Prescription Drug List (formulary) RxSelect®
Prescription Drugs - Up to 30 Day Supply of Covered Medications4
Tier 1 $10 after deductible
Tier 2 $25 after deductible
Tier 3 $50 after deductible
Tier 4 $100 after deductible
Maintenance Drugs - 90 Day Supply (Mail-Order, Retail90 ® )-selected drugs4
Tier 1 $10 after deductible
Tier 2 $50 after deductible
Tier 3 $150 after deductible
Preventive Prescription Drugs3-Up to 30 Day Supply of Covered Medications
4
Tier 1 $10
Tier 2 $25
Tier 3 $50
Tier 4 $100
Preventive Maintenance Drugs3-90 Day Supply (Mail-Order,Retail90 ® )-selected drugs
4
Tier 1 $10
Tier 2 $50
Tier 3 $150
Generic Substitution Required Generic required or must pay copay plus costdifference between name brand and generic
To remain compliant with state and federal regulations including the Affordable Care Act (ACA), these benefits are subject to change.
1 Refer to selecthealth.org/findadoctor to identify whether a provider is a primary or secondary care provider.
2 Refer to your Certificate of Coverage for more information.
3 Frequency and/or quantity limitations apply to some preventive care and MMS services.
6 SelectHealth provides a $4000 adoption indemnity as outlined by the state of Utah. Medical deductible, copay, or coinsurance listed under the benefit applies and may exhaust the benefits prior to any plan payments.
To contact Member Services, call 800-538-5038 weekdays, from 7:00 a.m. to 8:00 p.m., Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users should call 711.
See Professional, Inpatient, Outpatient, orMental Health and Chemical Dependency Services
4 Preauthorization is required for certain services. Benefits may be reduced or denied if you do not preauthorize certain services with nonparticipating providers. Please refer to Section 11--" Healthcare Management", in your Certificate of Coverage, for details.
5 All deductible/copay/coinsurance amounts are based on the allowed amounts and not on the providers billed charges. Nonparticipating Providers or Facilities have not agreed to accept the Allowed Amount for Covered Services. When this occurs, you are responsible to pay for any charges that exceed the amount that SelectHealth pays for Covered Services. These fees are called Excess Charges, and they do not apply to your Out-of-Pocket Maximum.
12
NEBO SCHOOL DISTRICT - SHARE OPTION PLAN G1021517 1001 L50A0126 09/01/2018
MEMBER PAYMENT SUMMARY
PARTICIPATING(In-Network)
When using participating providers, you are responsible to pay the amounts in this column. Services from nonparticipating providers are not covered (except emergencies).
CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment - Per Person None
Pre-Existing Conditions (PEC) None
Benefit Accumulator Period plan year
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET5 PARTICIPATING
Self Only Coverage, 1 person enrolled - per plan year
Deductible $1,600
Out-of-Pocket Maximum $3,250
Family Coverage, 2 or more enrolled - per plan year
Deductible $3,200
Out-of-Pocket Maximum $6,500
(Medical and Pharmacy Included in the Out-of-Pocket Maximum)
INPATIENT SERVICES PARTICIPATING
Medical, Surgical and Hospice4 20% after deductible
Skilled Nursing Facility4 - Up to 60 days per plan year 20% after deductible
Inpatient Rehab Therapy: Physical, Speech, Occupational4
Up to 40 days per plan year for all therapy types combined
PROFESSIONAL SERVICES PARTICIPATING
Office Visits & Minor Office Surgeries
Primary Care Provider (PCP)1
20% after deductible
Secondary Care Provider (SCP)1
20% after deductible
Allergy Tests See Office Visits Above
Allergy Treatment and Serum 20% after deductible
Major Surgery 20% after deductible
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) 20% after deductible
PREVENTIVE SERVICES AS OUTLINED BY THE ACA2,3 PARTICIPATING
Primary Care Provider (PCP)1
Covered 100%
Secondary Care Provider (SCP)1
Covered 100%
Adult and Pediatric Immunizations Covered 100%
Elective Immunizations - herpes zoster (shingles), rotavirus Covered 100%
Diagnostic Tests: Minor Covered 100%
Other Preventive Services
VISION SERVICES PARTICIPATING
Preventive Eye Exams Covered 100%
All Other Eye Exams 20% after deductible
OUTPATIENT SERVICES4 PARTICIPATING
Outpatient Facility and Ambulatory Surgical 20% after deductible
Ambulance (Air or Ground) - Emergencies Only 20% after deductible
Emergency Room - (Participating facility) 20% after deductible
Emergency Room - (Nonparticipating facility) 20% after deductible
Intermountain InstaCare®
Facilities, Urgent Care Facilities 20% after deductible
Intermountain KidsCare®
Facilities 20% after deductible
Intermountain Connect Care®
20% after deductible
Chemotherapy, Radiation and Dialysis 20% after deductible
Diagnostic Tests: Minor2
Covered 100% after deductible
Diagnostic Tests: Major2
20% after deductible
Home Health, Hospice, Outpatient Private Nurse 20% after deductible
Outpatient Rehab Therapy: Physical, Speech, Occupational 20% after deductible
Up to 20 visits per plan year for each therapy type
20% after deductible
Covered 100%
14
NEBO SCHOOL DISTRICT - SHARE OPTION PLAN G1021517 1001 L50A0126 09/01/2018MEMBER PAYMENT SUMMARY
PARTICIPATING(In-Network)
MISCELLANEOUS SERVICES PARTICIPATING
Durable Medical Equipment (DME)4
20% after deductible
Miscellaneous Medical Supplies (MMS)3
20% after deductible
Autism Spectrum DisorderApplied behavior analysis and behavioral health services up to $30,000 or600 hours/plan year, whichever is greater
Maternity and Adoption4,6 See Professional, Inpatient or Outpatient
Cochlear Implants4 See Professional, Inpatient or Outpatient
Infertility - Selected Services 50% after deductible (Max Plan Payment $1,500/ plan year; $5,000 lifetime)
Donor Fees for Covered Organ Transplants4
20% after deductible
TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime See Professional, Inpatient or Outpatient
OPTIONAL BENEFITS PARTICIPATING
Mental Health and Chemical Dependency4
Office Visits 20% after deductible
Inpatient 20% after deductible
Outpatient 20% after deductible
Residential Treatment2 20% after deductible
Injectable Drugs and Specialty Medications4 20% after deductible
PRESCRIPTION DRUGS
Prescription Drug List (formulary) RxSelect®
Prescription Drugs - Up to 30 Day Supply of Covered Medications4
Tier 1 $10 after deductible
Tier 2 $25 after deductible
Tier 3 $50 after deductible
Tier 4 $100 after deductible
Maintenance Drugs - 90 Day Supply (Mail-Order, Retail90 ® )-selected drugs4
Tier 1 $10 after deductible
Tier 2 $50 after deductible
Tier 3 $150 after deductible
Preventive Prescription Drugs3-Up to 30 Day Supply of Covered Medications
4
Tier 1 $10
Tier 2 $25
Tier 3 $50
Tier 4 $100
Preventive Maintenance Drugs3-90 Day Supply (Mail-Order,Retail90 ® )-selected drugs
4
Tier 1 $10
Tier 2 $50
Tier 3 $150
Generic Substitution Required Generic required or must pay copay plus costdifference between name brand and generic
To remain compliant with state and federal regulations including the Affordable Care Act (ACA), these benefits are subject to change.
1 Refer to selecthealth.org/findadoctor to identify whether a provider is a primary or secondary care provider.
2 Refer to your Certificate of Coverage for more information.
3 Frequency and/or quantity limitations apply to some preventive care and MMS services.
6 SelectHealth provides a $4000 adoption indemnity as outlined by the state of Utah. Medical deductible, copay, or coinsurance listed under the benefit applies and may exhaust the benefits prior to any plan payments.
To contact Member Services, call 800-538-5038 weekdays, from 7:00 a.m. to 8:00 p.m., Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users should call 711.
See Professional, Inpatient, Outpatient, orMental Health and Chemical Dependency Services
4 Preauthorization is required for certain services. Benefits may be reduced or denied if you do not preauthorize certain services with nonparticipating providers. Please refer to Section 11--" Healthcare Management", in your Certificate of Coverage, for details.
5 All deductible/copay/coinsurance amounts are based on the allowed amounts and not on the providers billed charges. Nonparticipating Providers or Facilities have not agreed to accept the Allowed Amount for Covered Services. When this occurs, you are responsible to pay for any charges that exceed the amount that SelectHealth pays for Covered Services. These fees are called Excess Charges, and they do not apply to your Out-of-Pocket Maximum.
15
NEBO SCHOOL DISTRICT - DUAL SHARE BASE PLAN G1021517 1001 L50A0133 09/01/2018
MEMBER PAYMENT SUMMARY
PARTICIPATING(In-Network)
When using participating providers, you are responsible to pay the amounts in this column. Services from nonparticipating providers are not covered (except emergencies).
CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment - Per Person None
Pre-Existing Conditions (PEC) None
Benefit Accumulator Period plan year
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET5 PARTICIPATING
Self Only Coverage, 1 person enrolled - per plan year
Deductible $2,700
Out-of-Pocket Maximum $2,700
Family Coverage, 2 or more enrolled - per plan year
Deductible - per person/family $2700/$5400
Out-of-Pocket Maximum - per person/family $2700/$5400
(Medical and Pharmacy Included in the Out-of-Pocket Maximum)
INPATIENT SERVICES PARTICIPATING
Medical, Surgical and Hospice4 Covered 100% after deductible
Skilled Nursing Facility4 - Up to 60 days per plan year Covered 100% after deductible
Inpatient Rehab Therapy: Physical, Speech, Occupational4
Up to 40 days per plan year for all therapy types combined
PROFESSIONAL SERVICES PARTICIPATING
Office Visits & Minor Office Surgeries
Primary Care Provider (PCP)1
Covered 100% after deductible
Secondary Care Provider (SCP)1
Covered 100% after deductible
Allergy Tests See Office Visits Above
Allergy Treatment and Serum Covered 100% after deductible
Major Surgery Covered 100% after deductible
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) Covered 100% after deductible
PREVENTIVE SERVICES AS OUTLINED BY THE ACA2,3 PARTICIPATING
Primary Care Provider (PCP)1
Covered 100%
Secondary Care Provider (SCP)1
Covered 100%
Adult and Pediatric Immunizations Covered 100%
Elective Immunizations - herpes zoster (shingles), rotavirus Covered 100%
Diagnostic Tests: Minor Covered 100%
Other Preventive Services
VISION SERVICES PARTICIPATING
Preventive Eye Exams Covered 100%
All Other Eye Exams Covered 100% after deductible
OUTPATIENT SERVICES4 PARTICIPATING
Outpatient Facility and Ambulatory Surgical Covered 100% after deductible
Ambulance (Air or Ground) - Emergencies Only Covered 100% after deductible
Emergency Room - (Participating facility) Covered 100% after deductible
Emergency Room - (Nonparticipating facility) Covered 100% after deductible
Intermountain InstaCare®
Facilities, Urgent Care Facilities Covered 100% after deductible
Intermountain KidsCare®
Facilities Covered 100% after deductible
Intermountain Connect Care®
Covered 100% after deductible
Chemotherapy, Radiation and Dialysis Covered 100% after deductible
Diagnostic Tests: Minor2
Covered 100% after deductible
Diagnostic Tests: Major2
Covered 100% after deductible
Home Health, Hospice, Outpatient Private Nurse Covered 100% after deductible
Outpatient Rehab Therapy: Physical, Speech, Occupational Covered 100% after deductible
Up to 20 visits per plan year for each therapy type
Covered 100% after deductible
Covered 100%
17
NEBO SCHOOL DISTRICT - DUAL SHARE BASE PLAN G1021517 1001 L50A0133 09/01/2018MEMBER PAYMENT SUMMARY
PARTICIPATING(In-Network)
MISCELLANEOUS SERVICES PARTICIPATING
Durable Medical Equipment (DME)4
Covered 100% after deductible
Miscellaneous Medical Supplies (MMS)3
Covered 100% after deductible
Autism Spectrum DisorderApplied behavior analysis and behavioral health services up to $30,000 or600 hours/plan year, whichever is greater
Maternity and Adoption4,6 See Professional, Inpatient or Outpatient
Cochlear Implants4 See Professional, Inpatient or Outpatient
Infertility - Selected Services Covered 100% after deductible (Max Plan Payment $1,500/ plan year; $5,000 lifetime)
Donor Fees for Covered Organ Transplants4
Covered 100% after deductible
TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime See Professional, Inpatient or Outpatient
OPTIONAL BENEFITS PARTICIPATING
Mental Health and Chemical Dependency4
Office Visits Covered 100% after deductible
Inpatient Covered 100% after deductible
Outpatient Covered 100% after deductible
Residential Treatment2 Covered 100% after deductible
Injectable Drugs and Specialty Medications4 Covered 100% after deductible
PRESCRIPTION DRUGS
Prescription Drug List (formulary) RxSelect®
Prescription Drugs - Up to 30 Day Supply of Covered Medications4
Tier 1 Covered 100% after deductible
Tier 2 Covered 100% after deductible
Tier 3 Covered 100% after deductible
Tier 4 Covered 100% after deductible
Maintenance Drugs - 90 Day Supply (Mail-Order, Retail90 ® )-selected drugs4
Tier 1 Covered 100% after deductible
Tier 2 Covered 100% after deductible
Tier 3 Covered 100% after deductible
Preventive Prescription Drugs3-Up to 30 Day Supply of Covered Medications
4
Tier 1 Covered 100%
Tier 2 Covered 100%
Tier 3 Covered 100%
Tier 4 Covered 100%
Preventive Maintenance Drugs3-90 Day Supply (Mail-Order,Retail90 ® )-selected drugs
4
Tier 1 Covered 100%
Tier 2 Covered 100%
Tier 3 Covered 100%
Generic Substitution Required Generic required or must pay copay plus costdifference between name brand and generic
To remain compliant with state and federal regulations including the Affordable Care Act (ACA), these benefits are subject to change.
1 Refer to selecthealth.org/findadoctor to identify whether a provider is a primary or secondary care provider.
2 Refer to your Certificate of Coverage for more information.
3 Frequency and/or quantity limitations apply to some preventive care and MMS services.
6 SelectHealth provides a $4000 adoption indemnity as outlined by the state of Utah. Medical deductible, copay, or coinsurance listed under the benefit applies and may exhaust the benefits prior to any plan payments.
To contact Member Services, call 800-538-5038 weekdays, from 7:00 a.m. to 8:00 p.m., Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users should call 711.
See Professional, Inpatient, Outpatient, orMental Health and Chemical Dependency Services
4 Preauthorization is required for certain services. Benefits may be reduced or denied if you do not preauthorize certain services with nonparticipating providers. Please refer to Section 11--" Healthcare Management", in your Certificate of Coverage, for details.
5 All deductible/copay/coinsurance amounts are based on the allowed amounts and not on the providers billed charges. Nonparticipating Providers or Facilities have not agreed to accept the Allowed Amount for Covered Services. When this occurs, you are responsible to pay for any charges that exceed the amount that SelectHealth pays for Covered Services. These fees are called Excess Charges, and they do not apply to your Out-of-Pocket Maximum.
18
NEBO SCHOOL DISTRICT - DUAL SHARE OPTION PLAN G1021517 1001 L50A0128 09/01/2018
MEMBER PAYMENT SUMMARY
PARTICIPATING(In-Network)
When using participating providers, you are responsible to pay the amounts in this column. Services from nonparticipating providers are not covered (except emergencies).
CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment - Per Person None
Pre-Existing Conditions (PEC) None
Benefit Accumulator Period plan year
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET5 PARTICIPATING
Self Only Coverage, 1 person enrolled - per plan year
Deductible $1,600
Out-of-Pocket Maximum $1,600
Family Coverage, 2 or more enrolled - per plan year
Deductible $3,200
Out-of-Pocket Maximum $3,200
(Medical and Pharmacy Included in the Out-of-Pocket Maximum)
INPATIENT SERVICES PARTICIPATING
Medical, Surgical and Hospice4 Covered 100% after deductible
Skilled Nursing Facility4 - Up to 60 days per plan year Covered 100% after deductible
Inpatient Rehab Therapy: Physical, Speech, Occupational4
Up to 40 days per plan year for all therapy types combined
PROFESSIONAL SERVICES PARTICIPATING
Office Visits & Minor Office Surgeries
Primary Care Provider (PCP)1
Covered 100% after deductible
Secondary Care Provider (SCP)1
Covered 100% after deductible
Allergy Tests See Office Visits Above
Allergy Treatment and Serum Covered 100% after deductible
Major Surgery Covered 100% after deductible
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) Covered 100% after deductible
PREVENTIVE SERVICES AS OUTLINED BY THE ACA2,3 PARTICIPATING
Primary Care Provider (PCP)1
Covered 100%
Secondary Care Provider (SCP)1
Covered 100%
Adult and Pediatric Immunizations Covered 100%
Elective Immunizations - herpes zoster (shingles), rotavirus Covered 100%
Diagnostic Tests: Minor Covered 100%
Other Preventive Services
VISION SERVICES PARTICIPATING
Preventive Eye Exams Covered 100%
All Other Eye Exams Covered 100% after deductible
OUTPATIENT SERVICES4 PARTICIPATING
Outpatient Facility and Ambulatory Surgical Covered 100% after deductible
Ambulance (Air or Ground) - Emergencies Only Covered 100% after deductible
Emergency Room - (Participating facility) Covered 100% after deductible
Emergency Room - (Nonparticipating facility) Covered 100% after deductible
Intermountain InstaCare®
Facilities, Urgent Care Facilities Covered 100% after deductible
Intermountain KidsCare®
Facilities Covered 100% after deductible
Intermountain Connect Care®
Covered 100% after deductible
Chemotherapy, Radiation and Dialysis Covered 100% after deductible
Diagnostic Tests: Minor2
Covered 100% after deductible
Diagnostic Tests: Major2
Covered 100% after deductible
Home Health, Hospice, Outpatient Private Nurse Covered 100% after deductible
Outpatient Rehab Therapy: Physical, Speech, Occupational Covered 100% after deductible
Up to 20 visits per plan year for each therapy type
Covered 100% after deductible
Covered 100%
20
NEBO SCHOOL DISTRICT - DUAL SHARE OPTION PLAN G1021517 1001 L50A0128 09/01/2018MEMBER PAYMENT SUMMARY
PARTICIPATING(In-Network)
MISCELLANEOUS SERVICES PARTICIPATING
Durable Medical Equipment (DME)4
Covered 100% after deductible
Miscellaneous Medical Supplies (MMS)3
Covered 100% after deductible
Autism Spectrum DisorderApplied behavior analysis and behavioral health services up to $30,000 or600 hours/plan year, whichever is greater
Maternity and Adoption4,6 See Professional, Inpatient or Outpatient
Cochlear Implants4 See Professional, Inpatient or Outpatient
Infertility - Selected Services Covered 100% after deductible (Max Plan Payment $1,500/ plan year; $5,000 lifetime)
Donor Fees for Covered Organ Transplants4
Covered 100% after deductible
TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime See Professional, Inpatient or Outpatient
OPTIONAL BENEFITS PARTICIPATING
Mental Health and Chemical Dependency4
Office Visits Covered 100% after deductible
Inpatient Covered 100% after deductible
Outpatient Covered 100% after deductible
Residential Treatment2 Covered 100% after deductible
Injectable Drugs and Specialty Medications4 Covered 100% after deductible
PRESCRIPTION DRUGS
Prescription Drug List (formulary) RxSelect®
Prescription Drugs - Up to 30 Day Supply of Covered Medications4
Tier 1 Covered 100% after deductible
Tier 2 Covered 100% after deductible
Tier 3 Covered 100% after deductible
Tier 4 Covered 100% after deductible
Maintenance Drugs - 90 Day Supply (Mail-Order, Retail90 ® )-selected drugs4
Tier 1 Covered 100% after deductible
Tier 2 Covered 100% after deductible
Tier 3 Covered 100% after deductible
Preventive Prescription Drugs3-Up to 30 Day Supply of Covered Medications
4
Tier 1 Covered 100%
Tier 2 Covered 100%
Tier 3 Covered 100%
Tier 4 Covered 100%
Preventive Maintenance Drugs3-90 Day Supply (Mail-Order,Retail90 ® )-selected drugs
4
Tier 1 Covered 100%
Tier 2 Covered 100%
Tier 3 Covered 100%
Generic Substitution Required Generic required or must pay copay plus costdifference between name brand and generic
To remain compliant with state and federal regulations including the Affordable Care Act (ACA), these benefits are subject to change.
1 Refer to selecthealth.org/findadoctor to identify whether a provider is a primary or secondary care provider.
2 Refer to your Certificate of Coverage for more information.
3 Frequency and/or quantity limitations apply to some preventive care and MMS services.
6 SelectHealth provides a $4000 adoption indemnity as outlined by the state of Utah. Medical deductible, copay, or coinsurance listed under the benefit applies and may exhaust the benefits prior to any plan payments.
To contact Member Services, call 800-538-5038 weekdays, from 7:00 a.m. to 8:00 p.m., Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users should call 711.
See Professional, Inpatient, Outpatient, orMental Health and Chemical Dependency Services
4 Preauthorization is required for certain services. Benefits may be reduced or denied if you do not preauthorize certain services with nonparticipating providers. Please refer to Section 11--" Healthcare Management", in your Certificate of Coverage, for details.
5 All deductible/copay/coinsurance amounts are based on the allowed amounts and not on the providers billed charges. Nonparticipating Providers or Facilities have not agreed to accept the Allowed Amount for Covered Services. When this occurs, you are responsible to pay for any charges that exceed the amount that SelectHealth pays for Covered Services. These fees are called Excess Charges, and they do not apply to your Out-of-Pocket Maximum.
21
SelectHealth Share®
As a SelectHealth Share member,
you will be engaged in your
healthcare, and we will work with
your employer to keep premiums as
low as possible. Please take a few
minutes to review the SelectHealth
Share engagement checklist. Use
this as your guide to make sure you
have met all your SelectHealth Share
required engagements. Each
engagement has a set time frame
(either 90 days or nine months from
the start of your plan year) when it
needs to be completed, so make
sure you finish on time.
SelectHealth Share Network Service Area
5,100+ Participating
Providers
21 Hospitals
INTERMOUNTAIN HEALTH ANSWERSSM
A 24/7 nurse line that allows you to
speak to a registered nurse who will
listen to your concerns, answer
medical questions, and help you
decide what course of action to
take. All you need is your phone.
Call 844-501-6600.
INTERMOUNTAIN CONNECT CARE®
Use your computer, tablet, or
phone to video connect with a
doctor or nurse practitioner
anytime (24/7 access). Visit
intermountainconnectcare.org
or download the app for Android
or iOS.
INTERMOUNTAIN INSTACARE®/KIDSCARE®
They’re open late—and are a great
choice for sore throats, broken
bones, sprains, headaches,
stomachaches, earaches, and other
urgent medical conditions. With
nearly 40 locations, there’s a site
near you. Use our app to reserve
your spot in line!
Free! Never more than
$49 per visit. See your
schedule of benefits for
coverage information.
Approximately doctor’s
office prices. Much
cheaper than the ER!
SELECTHEALTH ALSO INCLUDES:
SelectHealth Share members have access to many Intermountain
Medical Group® physicians and thousands more affiliated
providers. Additionally, you can use 20 Intermountain Healthcare
hospitals in Utah. Don’t see your hospital? Visit selecthealth.org/
providers to see all the hospitals included on SelectHealth Share.
• Cedar City Hospital
• Heber Valley Hospital
• Logan Regional Hospital
• Park City Hospital
• Primary Children’s Hospital
• Intermountain Medical Center®
• The Orthopedic SpecialtyHospital (TOSH®)
• Utah Valley Hospital
• McKay-Dee Hospital
• Dixie Regional Medical Center
• Mountain West Medical Center
22
90 DAYSA FEW EXTRAS
For employees who have a
condition, or are of a specific age
and/or gender, there are a few
special engagements that will help
you feel your best. And because
we care, these are also required.
Complete age- and gender-based screenings
• Women age 42-69: Onemammogram every two years
• Women age 24-64: One Pap testevery three years.
• Men and women age 51-80:One colonoscopy every10 years, or other colorectalcancer screening once every1-5 years
Complete prediabetes education. If your health screening/
assessment indicates you have
prediabetes, you will need to
complete prediabetes education
and health coaching. Plus, we’ll
reward you for improving your
health with Healthy Rewards Visa
cash cards.
Participate in disease management. If you have asthma,
diabetes, Chronic Obstructive
Pulmonary Disease (COPD), or
heart failure, you need to work
with a SelectHealth care manager.
Plus, we’ll reward you for
improving your health with
Healthy Rewards Visa® cash cards.
9 MONTHS
YOUR FIRST NINETY DAYS* (ALL EMPLOYEES)
Create an online My Health account. This is key to accessing your
Healthy Living tools and tracking your engagements. It’s your
health hub.
Pick your Primary Care Provider (PCP). Once you choose your doc,
make sure to tell us via My Health or by calling Member Services at
800-538-5038. Establishing a PCP is critical. From getting care
quickly when you need it to referrals, your PCP is your #1.
Attend a work-site health screening event or obtain the screening from a physician. This is how we establish your health baseline and
figure out the best plan for you.
Complete the annual online health assessment on the Healthy Living website (via your My Health account). Your assessment can
identify health risks so you can address those risks sooner rather
than later.
Establish and contribute to a Health Savings Account (HSA). This is for those of you who have a high-deductible health plan and
contribute at least 25 percent of your annual deductible. Consider
this your health bucks account—a real lifesaver when you need it.
YOUR FIRST NINE MONTHS* (ALL EMPLOYEES)
Complete at least one online digital health coaching program. Receive tips and resources on improving any health issues—and hey,
we all have at least one. Go to My Health, and then find “Digital
Coaching” in the Healthy Living section of your dashboard.
At least one 30-day check-in. So, remember that digital coaching
and health assessment you completed? You need to check-in so we
know how you’re doing. You’ll receive an email, and all you need to
do is click the email link to get started.
Get moving with Virgin Pulse. This is a two-part engagement. First,
create a Virgin Pulse account. This is where we track your activity.
Then, complete at least two of the wellness/activity campaigns.
Keep in mind, company team challenges, 7,000 steps in 20 days, or
Healthy Habits Challenges all count as activity campaigns.
*of the plan year.
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OUTSIDE OF YOUR SERVICE AREA
If you have an emergency or need urgent care
outside of your service area, participating benefits
apply to services you receive in a doctor’s office,
urgent care facility, or emergency room.
In an effort to reduce your medical out-of-pocket
expenses while traveling, SelectHealth® has an
arrangement with the MultiPlan and PHCS
networks. They accept an allowed amount for
covered services, which means that you will not
be responsible for excess charges when using
these providers.
Always present your ID card when visiting these
providers or facilities. The logos on the card give
you access to the networks.
To find MultiPlan and PHCS providers or
facilities, call MultiPlan at 800-678-7427 or
visit multiplan.com/selecthealth. For the greatest
savings, search for PHCS providers first. You can
also search for providers and facilities at
selecthealth.org/providers.
On the Move?
OUTSIDE OF THE COUNTRY
If you are traveling outside of the country and need
urgent or emergency care, visit the nearest doctor
or hospital. You may need to pay for the treatment
at the time of service. If you do, keep your receipt
and submit it along with a Claim Reimbursement
Form, which can be found on selecthealth.org.
DEPENDENT CHILDREN OUT OF AREA
Enrolled dependent children who live outside of
your service area (maybe they’re going to college
or living with another parent) can receive
participating benefits for covered services. To
qualify for this coverage, you will need to submit a
Dependent Address Change Form, which can be
found at selecthealth.org. The form contains
important instructions about which networks your
enrolled dependent child can use when living
outside your service area—please read it carefully.WEB multiplan.com; selecthealth.org/providers
PHONE 800-678-7427; 800-538-5038
NEED MORE INFORMATION?
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