Page 7 - RSD Guide

Select Med Plus and Select Care Plus Benefits (continued)

Participating Non-Participating
In-Network Out-of-Network
When using participating When using non-participating
providers, you are responsible to providers, you are responsible to
pay the amounts in this column pay the amounts in this column
Outpatient Services
Outpatient facility and ambulatory surgical 20% after deductible 40% after deductible
Ambulance (air or ground)—emergencies only 20% after deductible See participating beneit
Emergency room participating facility $250 after deductible See participating beneit
Emergency room non-participating facility $250 after deductible See participating beneit
Intermountain InstaCare facilities, urgent care facilities $50 40% after deductible
®
Intermountain KidsCare facilities $35 Not available
®
Chemotherapy, radiation, dialysis 20% after deductible 40% after deductible
Diagnostic tests: minor Covered 100% 40% after deductible
Diagnostic tests: major 20% after deductible 40% after deductible
Home health, hospice, outpatient private nurse 20% after deductible 40% after deductible
Outpatient rehab therapy: physical, speech, occupational $50 after deductible 40% after deductible
Up to 20 visits calendar year for each therapy type ($50 minimum copay)

Prescription Drug coverage for all medical plans
Tier 1 Tier 2 Tier3
$10 (most generics) 25% 50%

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

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