Individual Member Guide...drug store to convenient home delivery, you can get your prescriptions filled pretty ... Choosing the Right Care VALUE MED Alta View Hospital* American Fork

H E A LT H I S B E A U T I F U L

Individual Member GuideUTAH 2019

2 selecthealth.org selecthealth.org 3

Our mission is Helping People Live the Healthiest Lives Possible®. For more than 30 years,

we’ve been committed to helping members like you stay healthy, offering personalized

service, and providing access to high-quality care. Our mission is the foundation of

everything we do. Get to know us a little better.

LOCAL. We live, work, and play in the same communities you do. When you call us, you’re

talking to someone who lives in your community. We use the same providers and clinics you

do. Isn’t it nice to know that the person picking up the phone is a neighbor?

INTEGRATION. Integration with Intermountain Healthcare® gives you access to your favorite

doctors and facilities and allows us to work together for better healthcare at lower costs—

that’s a win-win!

SUPERIOR SERVICE. We can help you find the right doctor, clinic, or mental health provider

for your needs. We can even schedule an appointment—no referral necessary. When you call

us, a real person will pick up the phone in 20 seconds or less.

EMPOWERING YOU. Through tools like My Health and Medical Cost Estimator to helping

you get preventive services, treat chronic conditions, and take action to improve your health;

we want to give you the resources to be your own health advocate. We are more than just

an insurance company, we’re your health plan.

Why SelectHealth®

A health plan that works means healthy and happy members. Let’s make that happen.


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The Perfect Plan in Three Steps:

CHECK FOR SUBSIDIES ADVANCED PREMIUM TAX CREDIT ESTIMATOR

If you qualify for a subsidy, the

federal government will pay a

portion of your monthly premium.

Visit healthcare.gov/lower-costs

and enter some simple information,

including family size and household

income, to see if you qualify and

get an estimate.

COST-SHARE REDUCTION

In addition to a tax credit, you may

be eligible for cost-sharing

reduction plans that lower the

amount you pay out of pocket for

deductibles, coinsurance, and

copays. Members of a federally

recognized American Indian tribe

may also qualify for additional

cost-sharing benefits.

RESEARCH PLANS We know that finding the right plan

can be confusing. That’s why it’s

important to understand what the

details mean before choosing a plan.

Individual plans are organized by

Metal Tier, Plan Type, and Network.

Each one of these categories

dictates which type of benefits and

rates you can expect to see for

each plan design.

Metal Tiers

Choose from four metal tiers—

Bronze, Expanded Bronze, Silver, and Gold. These are largely based

on how the cost of healthcare is split

between you and us.

BRONZEWe pay 60% on average.

You pay about 40%.

EXPANDED BRONZEWe pay 65% on average.

You pay about 35%.

SILVERWe pay 70% on average.

You pay about 30%.

GOLDWe pay 80% on average.

You pay about 20%.

Plan Types

Plan types are categorized by

Traditional, HealthSaveSM, Benchmark,

and Catastrophic. Each type of plan

offers different features depending

on your needs, budget, and lifestyle.

With a Traditional plan, you can

expect a more classic-style plan.

Choose from standard deductibles,

no deductibles for office visits, or

limited deductibles for office visits.

HealthSave plans give you the

opportunity to pair your plan with a

Health Savings Account (HSA). And

a Catastrophic plan is developed for

just those who are under age 30 or

qualify for a hardship exemption.

Learn more about these plans on

pages 8 and 9, at selecthealth.org,

or by visiting healthcare.gov.

Networks

We offer two provider networks

that span the entire state of Utah.

Generally, our SelectHealth MedSM

network offers a larger network of

providers, while our SelectHealth

ValueSM network offers lower

premiums. These will dictate where in

the state you are able to receive care.

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MAKE YOUR FIRST PAYMENT

Visit selecthealth.org/applyonline

to use our convenient online

application. The application must

be completed and signed

electronically. If you need help with

your application, call Individual Sales

at 855-442-0220, or you can call

your agent.

You’ll need to make your first month’s payment before you receive an ID card.

ALL YOUR INFO IN ONE PLACE

Once enrolled, you’ll have access

to My Health. Here you’ll have

important health and benefit

information. We also provide a

number of health resources,

including LiVe Well tools, to help

you achieve your wellness goals.

Learn more on page 11.

INTERMOUNTAIN CONNECT CARE®

Healthcare on your schedule—no lines, no waiting room. Connect Care is a convenient way to talk to a provider about urgent medical issues, no appointment necessary.

Only $10 for Individual members!*

Download the app or visit intermountainconnectcare.org to get started.

*Before deductible. $49 before deductible for those on a HealthSave plan.

Connect Care is now only $10* for Individual members!


PCP

Connect Care

Health Answers

Specialists

HospitalsLocal Clinics

Pharmacies InstaCare

YOUR COMPLETE

CARE

Before scheduling an appointment,

consider all of your care options.

PRIMARY CARE PROVIDERSA Primary Care Provider (PCP) is someone in family medicine, internal medicine, or another provider you see regularly. You can trust a PCP to know your health history, be your partner in preventive care, and help you find other doctors when you need them.

INTERMOUNTAIN CONNECT CARE®Visit a provider 24/7 via live online video. At only $10 a visit for most plans, this is a great care option without even having to leave home.

INTERMOUNTAIN INSTACARE®What’s open late and costs less than the ER? Our InstaCare℠ and KidsCare℠ clinics. If you need urgent care, these are great options.

HOSPITALS Intermountain hospitals span the state of Utah, offering a variety of care and services. Think heart care, cancer treatment, transplant services, women and newborns, and much more—you name it, they can treat it.

SPECIALISTS When you need more than your PCP, our network of specialists and surgeons can help—and there are thousands to choose from.

LOCAL CLINICS Intermountain community clinics and contracted clinics are in your area, so you never have to drive far to get the care you need. Plus, some clinics have extended hours!

PHARMACIES From major national chains to the corner drug store to convenient home delivery, you can get your prescriptions filled pretty much anywhere.

INTERMOUNTAIN HEALTH ANSWERS® Our free nurse line is available 24/7. Call about any medical condition and we’ll help ease your mind.

IN-NETWORK HOSPITALS AND CLINICS

Depending on the network you choose, you’ll have access

to high-quality hospitals, clinics, and doctors in your area.

Choosing the Right Care

VALUE MED

Alta View Hospital*

American Fork Hospital*

Intermountain Medical Center*

LDS Hospital*

McKay-Dee Hospital*

Orem Community Hospital*

Primary Children’s Hospital*

Riverton Hospital*

TOSH - The Orthopedic Specialty Hospital*

Utah Valley Hospital*

Bear River Valley Hospital*

Delta Community Hospital*

Dixie Regional Medical Center* (River Road Campus)

Dixie Regional Medical Center*

Fillmore Community Hospital*

Garfield Memorial Hospital*

Heber Valley Medical Center*

Logan Regional Hospital*

Park City Hospital*

Sanpete Valley Hospital*

Sevier Valley Hospital*

Cedar City Hospital*

Ashley Valley Medical Center

Beaver Valley Hospital

Central Valley Medical Center

Davis Hospital & Medical Center

Franklin County Medical Center*

Gunnison Valley Hospital

Huntsman Cancer Hospital (For Med: Cancer Treatment Only)

Kane County Hospital

Milford Valley Memorial Hospital

Moab Regional Hospital

Mountain West Medical Center

San Juan Hospital

Uintah Basin Medical Center

Blue Mountain Hospital

Castleview Hospital

Cassia Regional Hospital**

Portneuf Medical Center*

St. Luke’s Rehab Hospital - IP Acute Care Unit

Staying healthy just got a little easier on your wallet. As a SelectHealth member, you can get reimbursed for gym memberships through our Healthy Living® program. Hitting the gym never felt so good!

Get Fitness Reimbursements

> Choose a club in the Virgin Pulse network or any gym you like best

> Get the guaranteed lowest gym membership rate through the Virgin Pulse network, with more than 12,000 participating clubs nationally

> Try a free one-week trial membership

> Submit your request for a fitness club and gym membership reimbursement

> Receive up to $240 per year, reimbursed quarterly

Here’s How It Works

> Be age 18 or older

> Create a My Health account

> Complete the Johnson & Johnson online health assessment

> Provide receipts for membership payments

You may be eligible for other benefits too, such as discounts on home fitness equipment, streaming fitness videos, or race entry fees. To get started or learn more, log in to My Health at selecthealth.org.

Gym Membership Program

*Idaho Facility*Intermountain-owned Facility


SELECTHEALTH HEALTHSAVE®

Most HealthSaveSM plans are designed to be paired with a Health Savings Account (HSA). With a HealthSave plan, you

have more control over your healthcare dollars. Some HealthSave plans are cost-share reduction plans; however, not all

cost-share reduction plans are eligible for an HSA.

CATASTROPHIC PLAN

If you are younger than age 30, or if you qualify for a hardship exemption, you may consider purchasing a catastrophic

health plan. These plans have lower premiums, higher deductibles, and higher out-of-pocket maximums, making them

ideal for those who only want protection from very high medical costs. These plans are not eligible for a premium subsidy.

TRADITIONAL PLANS

Traditional plans are a popular choice for those who’d like a traditional or

“classic” plan, including coverage for medical services, preventive care, and

prescription drugs. Choose a deductible and benefits that work for you.

Some of these plans have a deductible waiver or a limited deductible

waiver for Primary Care, Mental Health, and Specialty Care office visits.

On these plans, the deductible only applies for some or a limited number

of office visits.

BRONZEWe pay 60% on average.

EXPANDED BRONZEWe pay 65% on average.

SILVERWe pay 70% on average.

GOLDWe pay 80% on average.

CATASTROPHIC We pay less than 60% on average.

2019 UTAH PLAN

Catastrophic

SelectHealth HealthSave3, 4

Benchmark1

Standard Deductible

No-Deductible Office Visits

Limited Office Visit Waiver2

Catastrophic 7900

Bronze 6750

Expanded Bronze 3600

Silver 3250

Bronze 79005

Bronze 6600


Silver 2100


Silver 4000 - Copay

Silver 2700

Silver 2600 (Off Exchange Only)

Gold 1500

Bronze 7600

Expanded Bronze 4800 - Copay

Deductible

Single $7,900 $6,750 $3,600 $3,250 $7,900 $6,600 $2,850 $2,100 $7,900 $4,000 $2,700 $2,600 $1,500 $7,600 $4,800

Family $15,800 $13,5003 $7,2003 $6,5003 $15,800 $13,200 $5,700 $4,200 $15,800 $8,000 $5,400 $5,200 $3,000 $15,200 $9,600

Out-of-Pocket Max

Single $7,900 $6,750 $6,750 $6,750 $7,900 $7,900 $7,900 $7,900 $7,900 $7,900 $7,900 $7,900 $6,000 $7,900 $7,900

Family $15,800 $13,5004 $13,5004 $13,5004 $15,800 $15,800 $15,800 $15,800 $15,800 $15,800 $15,800 $15,800 $12,000 $15,800 $15,800

Primary Care Provider (PCP)

$35 for first 3 PCP and/or mental health office

visits, then covered 100% after deductible

100% after deductible

$25 after deductible




$35 after deductible $35 after deductible $35 $25 $35 $35 $25 $50 $35

Secondary Care Provider (SCP) 100% after deductible 100% after

deductible$40 after

deductible$40 after

deductible100% after deductible



$60 after deductible $60 $60 $60 $60 $40 $65 after

deductible$60 after

deductible

Preventive Care and Immunizations Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered

100%Covered

100% Covered 100%

Minor Diagnostic Tests 100% after deductible 100% after







100% after deductible Covered 100% 100% after

deductible Covered 100% Covered 100%



Inpatient Hospital Services 100% after deductible 100% after








$650 per day after deductible (up to 5 days)





$650 per day after deductible (up to 5 days)

Outpatient Services 100% after deductible 100% after














Emergency Room 100% after deductible 100% after deductible














Rx Deductible Per Person Medical and Rx Combined $1,000 $1,000 $1,000 Medical and

Rx Combined $2,500 $1,000 $1,000 $500 $1,500 $2,500

Tier 1 Drugs 100% after deductible 100% after deductible



100% after deductible $20 $15 $15 $10 $25 $15 $15 $15 $20 $25




100% after deductible $30 $25 $25 $20 $35 $25 $25 $25 $30 $35





25% after pharmacy deductible




$45 after pharmacy deductible


































1 Benchmark plans cover only Essential Health Benefits (EHBs) as defined by the state of Utah. Some non-EHBs like prosthetics and crutches are not covered under these plans. For more information, call Individual Sales at 855-442-0220 or visit healthcare.gov.

2 The deductible is waived for all Primary Care Provider and Mental Health office visits. In addition, the first visit to an urgent care clinic is not subject to the deductible. This visit is subject to a copay only. Starting with the second visit to an urgent care clinic, the deductible and copay will apply.

3 When two or more are enrolled on a HealthSave plan, only the family deductible applies.

4 When two or more are enrolled, no single person in a family will pay more than the single out-of-pocket maximum.

5 This plan does not include coverage for pediatric dental care which is considered an essential health benefit under the Affordable Care Act. Pediatric dental care is available in the market and can be purchased as a stand-alone product. Please contact your insurance agent or the Federally Facilitated Marketplace if you wish to purchase a stand-alone dental care product.


Mobile App – Everything at Your Fingertips

If you’ve got a phone, we’ve got you covered. With the SelectHealth mobile app,

you have access to your health plan whenever—and wherever—you need it.

GET IN LINE

Curious about the wait time at your local InstaCare? Use the

app to see wait times and even reserve your place in line

with the touch of a button.

SEARCH FOR DOCTORS AND FACILITIES

Avoid searching all over for your next visit. View

Intermountain hospitals, facilities, and InstCares in your area

on a responsive map. Quickly locate doctors by name,

specialty, rating, and more.

ID CARD

Forgot your ID card at home? Don’t worry. The Mobile App

has got you covered with the ability to view, email, and even

fax an image of your ID card. This is especially helpful when

you need to reference your plan details or send a card to

a provider.

RX INFORMATION

Look up prescription drug costs, which drug tier they fall

into, and if they are considered a maintenance drug before

heading to the pharmacy. You’ll also be able to learn about

any potentially dangerous drug interactions prior to use.

And when you’re ready to pick up your Rx, use the handy

Pharmacy Search to find a location closest to you.

MEDICAL COST ESTIMATOR

Get an estimate for common healthcare services. For

example, find out ahead of time how much to plan for

when having a baby, including charges for the facility,

provider, and anesthesiologist, if applicable. Bundling

these numbers together, we’ll estimate how much your

plan will cover and what you will pay.

YOUR HEALTH PLAN

View claims, get a snapshot of year-to-date deductible

and out-of-pocket maximum totals, and search for a

doctor. It’s all here and updated to the minute.

CHAT WITH US

No time for a phone call? Use our secure chat feature to

talk with Member Services online. Whether you need to

know if your medication will be covered or how much a

doctor’s bill was, chat can help.

MESSAGE YOUR DOCTOR

With a few clicks you can send a message to your

Intermountain doctor about your last visit, recent lab

results, or questions about your new prescription.

My Health – Take Charge of Your Health

My Health can be accessed from your mobile device or computer by visiting

selecthealth.org. Once you log in, click the SelectHealth icon or link and

enjoy being an informed healthcare consumer.

Urgent Care

Select Med

My Location Change Location List View

5min wait

Instacare

5min wait

Instacare

5min wait

Instacare

Closed

Kidscare

5min wait

Instacare

Map Satellite


Your Prescription Benefits

90-DAY MAINTENANCE DRUG BENEFIT

The 90-day maintenance drug benefit allows you to

obtain a 90-day supply of certain generic medications.

It applies to drugs that you have been using for at least

one month and expect to continue using for the next

year. Your member responsibility (e.g., copay or

coinsurance amounts) may be lower when you fill

prescriptions using the 90-day benefit.

ONLINE TOOLS

It’s easy to view your family’s prescription history or find

out how much a drug will cost. Log in to My Health at

selecthealth.org to access these useful pharmacy tools:

> Review drug coverage

> View Rx claims

> Compare drug prices

> Find in-network pharmacies

> Check for drug interactions

PRESCRIPTION DRUGS

Coverage is divided into five tiers (levels). Each drug is

covered under a specific tier that corresponds to a copay

or coinsurance amount—this is the amount you pay.

Drugs on lower tiers may provide the treatment you need

at the best value.

Tier 1 – Lowest cost (mostly generic drugs)

Tier 2 – Medium cost (non-preferred generic and some

brand-name drugs)

Tier 3 – Higher cost (generic and brand-name drugs)

Tier 4 – Highest cost (mostly brand-name drugs)

Tier 5 – Highest cost (injectable drugs and

specialty medications)

PRESCRIPTION DRUG LIST (PDL)

Individual plans use our RxCore® PDL. Search for your

drug on our website (see Pharmacy) to find the tier and

any special requirements.

SPECIAL REQUIREMENTS

Some drugs require step therapy or preauthorization

before they will be covered by your plan.

Step Therapy – If your drug requires step therapy, your

doctor must first prescribe an alternative drug. These

are generally more cost effective and do not compromise

clinical quality. Step therapy may be waived for

medical necessity.

Preauthorization – This means that your doctor must

contact us for approval before your drug will be covered.

Prescription drug benefits for everyone, plus access to more than 45,000 pharmacies nationwide.

There are two ways to fill a 90-day

prescription: A local pharmacy that

participates in our Retail90® program (search

for Retail90 pharmacies online) or the Intermountain

Home Delivery Pharmacy (intermountainrx.org).


95% OF DENTISTS

Over 95% of dentists in Utah

participate in our Classic network.

So, you won’t have to worry

about your dentist being in

our network.

ONE-STOP CUSTOMER SERVICE

Get the same exceptional

customer service team for all

medical and dental benefit

questions. Call 800-538-5038—

no need to remember two phone

numbers or company names.

MIX AND MATCH

You can mix and match benefit

options with our Classic network,

or if you are located along the

Wasatch Front, you can even

match a benefit plan with our

Fundamental or Prime

networks. It’s your choice.

SelectHealth Dental®

SelectHealth Dental provides comprehensive coverage to keep your teeth healthy.

With hundreds of providers to choose from, top-ranked customer service, and online

support, there’s plenty to smile about.

2019 UTAH PLAN

BENEFIT OPTIONS

Benefits Participating Nonparticipating (Optional) Participating Nonparticipating

(Optional)

Deductible (Individual/Family)

Annual Maximum Plan Payment Options (Individual)

$50/150

$750 or $1,000

$50/150

$750 or $1,000

$50/150

$1,500

$50/150

$1,500

Preventive and Diagnostic (No waiting period)Oral exams, cleanings, fluoride, X-rays No charge 20% No charge or 10% 30%

Basic(Six-month waiting period without prior coverage) Fillings and oral surgery





Major(12-month waiting period without prior coverage)Crowns, bridges, dentures, endodontics, and periodontics





OUR PLANS

Our plans are designed to provide coverage for hospital,

medical, preventive care, and surgical expenses incurred

as a result of a covered accident or illness. Coverage is

provided through in-network providers for daily hospital

room and board, miscellaneous hospital services,

anesthesia services, in-hospital medical services, and

out-of-hospital care. Coverage is subject to any

deductible, copay provisions, or other limitations that

may be set forth in your Contract.

ELIGIBILITY

You and your dependents may apply for coverage if you

are a resident of Utah and not eligible for Medicare.

Eligible dependents include the subscriber’s legal spouse,

children younger than age 26, eligible disabled children

older than age 26, and children who are under court-

ordered legal guardianship until legal guardianship ends.

See your Contract for more details on guardianship.

TERMINATION

Your coverage will not terminate (end) for health reasons.

However, your coverage may end according to the terms

of your Contract, including any of these reasons:

> Nonpayment of premiums

> Fraud or intentional misrepresentation of material fact

> You no longer reside, live, or work in the service area

If we do not receive a premium or we are unable to

collect a premium, you will be notified.

EXCLUDED SERVICES

Certain services are not covered by your plan. For a list

of excluded services, see your member materials or

visit selecthealth.org/exclusions.

EXCESS CHARGES

These are charges from providers and facilities that exceed

the SelectHealth allowed amount for covered services.

When you use an out-of-network provider or facility, you

will be responsible for any incurred excess charges. These

charges do not apply to your out-of-pocket maximum.

APPEALS/ UTILIZATION MANAGEMENT (UM)

For information about what requires preauthorization, our

care management programs, or how to file an appeal, see

your member materials or visit our Member Resources

page selecthealth.org/policy.

SelectHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a SelectHealth: 1-800-538-5038 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 SelectHealth: 1-800-538-5038 (TTY: 711).

General Medical Information

© 2018 SelectHealth. All rights reserved. 8423281 10/18

We’re committed to helping you stay healthy by providing access to high-quality

healthcare at an affordable cost, giving superior service, and offering the tools you

need to make smart decisions. For more information about our health plan options,

contact our Individual Sales department at 855-442-0220.

Documents

Individual Member Guide...drug store to convenient home delivery, you can get your prescriptions filled pretty ... Choosing the Right Care VALUE MED Alta View Hospital* American Fork