Page 5 - RSD Guide
P. 5
SelectHealth Select Value Benefits
Participating
Medical deductible and out-of-pocket Individual/Family
Calendar year deductible and out-of-pocket maximum; deductible is included in the out-of-pocket
maximum
Deductible $500/$1,000
Out-of-pocket maximum
This amount is your deductible + your maximum $3,000/$6,000
coinsurance and copay
Inpatient Services
Medical, surgical, hospice, emergency admissions
Skilled nursing facility
Up to 60 days/calendar year 20% after deductible
Rehab therapy: physical, speech, occupational
Up to 40 days/calendar year for all therapy types combined
Professional Services
Ofice visits and ofice surgeries
Primary Care Provider (PCP) $35
Secondary Care Provider (SCP) $50
Allergy tests See ofice visits
Allergy treatment and serum 20%
Physician’s fees—medical, surgical, anesthesia 20% after deductible
Preventive Services as Outlined by the ACA
Ofice visits (PCP/SCP)
Adult and pediatric immunizations Covered 100%
Diagnostic tests: minor
Other preventive services
Outpatient Services
Outpatient facility and ambulatory surgical 20% after deductible
Ambulance (air or ground)—emergencies only 20% after deductible
Emergency room pa1ticipating facility $250 after deductible
Emergency room nonparticipating facility $250 after deductible
Intermountain InstaCare facilities, urgent care facilities $50
®
Intermountain KidsCare facilities $35
®
Chemotherapy, radiation, dialysis 20% after deductible
Diagnostic tests: minor Covered 100%
Diagnostic tests: major 20% after deductible
Home health, hospice, outpatient private nurse 20% after deductible
Outpatient rehab therapy: physical, speech, occupational $50 after deductible
Up to 20 visits calendar year for each therapy type
5
Participating
Medical deductible and out-of-pocket Individual/Family
Calendar year deductible and out-of-pocket maximum; deductible is included in the out-of-pocket
maximum
Deductible $500/$1,000
Out-of-pocket maximum
This amount is your deductible + your maximum $3,000/$6,000
coinsurance and copay
Inpatient Services
Medical, surgical, hospice, emergency admissions
Skilled nursing facility
Up to 60 days/calendar year 20% after deductible
Rehab therapy: physical, speech, occupational
Up to 40 days/calendar year for all therapy types combined
Professional Services
Ofice visits and ofice surgeries
Primary Care Provider (PCP) $35
Secondary Care Provider (SCP) $50
Allergy tests See ofice visits
Allergy treatment and serum 20%
Physician’s fees—medical, surgical, anesthesia 20% after deductible
Preventive Services as Outlined by the ACA
Ofice visits (PCP/SCP)
Adult and pediatric immunizations Covered 100%
Diagnostic tests: minor
Other preventive services
Outpatient Services
Outpatient facility and ambulatory surgical 20% after deductible
Ambulance (air or ground)—emergencies only 20% after deductible
Emergency room pa1ticipating facility $250 after deductible
Emergency room nonparticipating facility $250 after deductible
Intermountain InstaCare facilities, urgent care facilities $50
®
Intermountain KidsCare facilities $35
®
Chemotherapy, radiation, dialysis 20% after deductible
Diagnostic tests: minor Covered 100%
Diagnostic tests: major 20% after deductible
Home health, hospice, outpatient private nurse 20% after deductible
Outpatient rehab therapy: physical, speech, occupational $50 after deductible
Up to 20 visits calendar year for each therapy type
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