medical · skilled nursing facility4 - up to 60 days per plan year 20% after ... primary care...

MedicalSelectHealth ‐ BasePlan

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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


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


Covered 100%


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®


Chemotherapy, Radiation and Dialysis 20% after deductible

Diagnostic Tests: Minor2

Covered 100% after deductible

Diagnostic Tests: Major2


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


Covered 100%

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NEBO SCHOOL DISTRICT - SHARE BASE PLAN G1021517 1001 L50A0130 09/01/2018MEMBER PAYMENT SUMMARY


MISCELLANEOUS SERVICES PARTICIPATING

Durable Medical Equipment (DME)4


Miscellaneous Medical Supplies (MMS)3


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


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




Maintenance Drugs - 90 Day Supply (Mail-Order, Retail90 ® )-selected drugs4




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.

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MedicalSelectHealth ‐ OptionPlan

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NEBO SCHOOL DISTRICT - SHARE OPTION PLAN G1021517 1001 L50A0126 09/01/2018










Deductible $1,600



Deductible $3,200




Medical, Surgical and Hospice4 20% after deductible

Skilled Nursing Facility4 - Up to 60 days per plan year 20% after deductible










Allergy Treatment and Serum 20% after deductible

Major Surgery 20% after deductible

Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) 20% after deductible



Covered 100%


Covered 100%







All Other Eye Exams 20% after deductible


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


Facilities, Urgent Care Facilities 20% after deductible


Facilities 20% after deductible



Chemotherapy, Radiation and Dialysis 20% after deductible





Home Health, Hospice, Outpatient Private Nurse 20% after deductible

Outpatient Rehab Therapy: Physical, Speech, Occupational 20% after deductible



Covered 100%

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NEBO SCHOOL DISTRICT - SHARE OPTION PLAN G1021517 1001 L50A0126 09/01/2018MEMBER PAYMENT SUMMARY










Infertility - Selected Services 50% after deductible (Max Plan Payment $1,500/ plan year; $5,000 lifetime)






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












4

Tier 1 $10

Tier 2 $25

Tier 3 $50

Tier 4 $100


4

Tier 1 $10

Tier 2 $50

Tier 3 $150











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MedicalSelectHealth – DualEmployeeBasePlan

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NEBO SCHOOL DISTRICT - DUAL SHARE BASE PLAN G1021517 1001 L50A0133 09/01/2018










Deductible $2,700



Deductible - per person/family $2700/$5400

Out-of-Pocket Maximum - per person/family $2700/$5400



Medical, Surgical and Hospice4 Covered 100% after deductible

Skilled Nursing Facility4 - Up to 60 days per plan year Covered 100% after deductible










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



Covered 100%


Covered 100%







All Other Eye Exams Covered 100% after deductible


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


Facilities, Urgent Care Facilities Covered 100% after deductible


Facilities Covered 100% after deductible



Chemotherapy, Radiation and Dialysis Covered 100% after deductible





Home Health, Hospice, Outpatient Private Nurse Covered 100% after deductible

Outpatient Rehab Therapy: Physical, Speech, Occupational Covered 100% after deductible



Covered 100%

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NEBO SCHOOL DISTRICT - DUAL SHARE BASE PLAN G1021517 1001 L50A0133 09/01/2018MEMBER PAYMENT SUMMARY










Infertility - Selected Services Covered 100% after deductible (Max Plan Payment $1,500/ plan year; $5,000 lifetime)






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



Tier 1 Covered 100% after deductible









4

Tier 1 Covered 100%

Tier 2 Covered 100%

Tier 3 Covered 100%

Tier 4 Covered 100%


4

Tier 1 Covered 100%

Tier 2 Covered 100%

Tier 3 Covered 100%











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MedicalSelectHealth – DualEmployeeOptionPlan

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NEBO SCHOOL DISTRICT - DUAL SHARE OPTION PLAN G1021517 1001 L50A0128 09/01/2018










Deductible $1,600



Deductible $3,200




Medical, Surgical and Hospice4 Covered 100% after deductible

Skilled Nursing Facility4 - Up to 60 days per plan year Covered 100% after deductible










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



Covered 100%


Covered 100%







All Other Eye Exams Covered 100% after deductible


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


Facilities, Urgent Care Facilities Covered 100% after deductible


Facilities Covered 100% after deductible



Chemotherapy, Radiation and Dialysis Covered 100% after deductible





Home Health, Hospice, Outpatient Private Nurse Covered 100% after deductible

Outpatient Rehab Therapy: Physical, Speech, Occupational Covered 100% after deductible



Covered 100%

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NEBO SCHOOL DISTRICT - DUAL SHARE OPTION PLAN G1021517 1001 L50A0128 09/01/2018MEMBER PAYMENT SUMMARY










Infertility - Selected Services Covered 100% after deductible (Max Plan Payment $1,500/ plan year; $5,000 lifetime)






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












4

Tier 1 Covered 100%

Tier 2 Covered 100%

Tier 3 Covered 100%

Tier 4 Covered 100%


4

Tier 1 Covered 100%

Tier 2 Covered 100%

Tier 3 Covered 100%











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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

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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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medical · skilled nursing facility4 - up to 60 days per plan year 20% after ... primary care...

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