Page 7 - Guide

Participating Non-Participating
2016–2017 Beneits Enrollment
In-Network Out-of-Network
When using participating When using non-
providers, you are participating providers,
responsible to pay the you are responsible to
amounts in this column pay the amounts in this
column
Preventive Services as Outlined by the ACA
Office Visits (PCP/SCP) Covered 100% Not covered
Adult and Pediatric Immunizations
Diagnostic Tests: Minor
Other Preventive Services
Outpatient Services
Outpatient Facility and Ambulatory 20% after deductible 50% after deductible
Surgical
Ambulance (air or ground)—Emergencies 20% after deductible See participating benefit
Only
Emergency Room Participating Facility $350 copay $350 copay
Emergency Room Non-Participating Facility $350 copay $350 copay
Intermountain InstaCare Facilities, Urgent $40 50% after deductible
®
Care Facilities
Intermountain KidsCare Facilities $25 Not available
®
Chemotherapy, Radiation, Dialysis 20% after deductible 50% after deductible
Diagnostic Tests: Minor Covered 100% 50% after deductible
Diagnostic Tests: Major 20% after deductible 50% after deductible
Home Health, Hospice, Outpatient Private 20% after deductible 50% after deductible
Nurse
Outpatient Rehab Therapy: Physical, $40 copay 50% after deductible
Speech, Occupational
Up to 20 visits calendar year for each
therapy type

Prescription Drug Coverage For All Medical Plans
Tier 1 Tier 2 Tier3
$10 (most generics) 25% 50%

For speciic information about which tier your prescription falls into, contact
SelectHealth at 800.538.5038 or www.selecthealth.org.

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