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PARTICIPATING NONPARTICIPATING (In-Network) (Out-of-Network) SELECTHEALTH NETWORK CONDITIONS AND LIMITATIONS Pre-Existing Conditions (PEC) Benefit Accumulator Period Maximum Annual Out-of-Network Payment - (per calendar year) None None MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET5 PARTICIPATING NONPARTICIPATING Self Only Coverage, 1 person enrolled - per calendar year Deductible $2,000 $4,000 Out-of-Pocket Maximum $3,500 $7,000 Family Coverage, 2 or more enrolled - per calendar year Deductible - per person/family $2000/$4000 $4000/$8000 Out-of-Pocket Maximum - per person/family $3500/$7000 $7000/$14000 (Medical and Pharmacy Included in the Out-of-Pocket Maximum) INPATIENT SERVICES PARTICIPATING NONPARTICIPATING Medical, Surgical and Hospice4 20% after deductible 40% after deductible Skilled Nursing Facility4 - Up to 60 days per calendar year 20% after deductible 40% after deductible Inpatient Rehab Therapy: Physical, Speech, Occupational4 20% after deductible 40% after deductible Up to 40 days per calendar year for all therapy types combined PROFESSIONAL SERVICES PARTICIPATING NONPARTICIPATING Office Visits & Minor Office Surgeries Primary Care Provider (PCP)1 $30 40% after deductible Secondary Care Provider (SCP)1 $30 40% after deductible Allergy Tests See Office Visits Above 50% after deductible Allergy Treatment and Serum 20% 50% after deductible Major Surgery 20% 40% after deductible Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) 20% after deductible 40% after deductible PREVENTIVE SERVICES AS OUTLINED BY THE ACA2,3 PARTICIPATING NONPARTICIPATING Primary Care Provider (PCP)1 Covered 100% 50% after deductible Secondary Care Provider (SCP)1 Covered 100% 50% after deductible Adult and Pediatric Immunizations Covered 100% 50% after deductible Elective Immunizations - herpes zoster (shingles), rotavirus Covered 100% 50% after deductible Diagnostic Tests: Minor Covered 100% 50% after deductible Other Preventive Services 50% after deductible VISION SERVICES PARTICIPATING NONPARTICIPATING Preventive Eye Exams Covered 100% 50% after deductible All Other Eye Exams $30 40% after deductible OUTPATIENT SERVICES4 PARTICIPATING NONPARTICIPATING Outpatient Facility and Ambulatory Surgical 20% after deductible 40% after deductible Ambulance (Air or Ground) - Emergencies Only 20% after deductible See Participating Benefit Emergency Room - (Participating facility) $100 then 20% after deductible See Participating Benefit Emergency Room - (Nonparticipating facility) $100 then 20% after deductible See Participating Benefit Urgent Care Facilities $30 40% after deductible Intermountain Connect Care®/Virtual Visits $10 40% after deductible Chemotherapy, Radiation and Dialysis 20% after deductible 40% after deductible Diagnostic Tests: Minor2 Covered 100% 40% after deductible Diagnostic Tests: Major2 20% after deductible 40% after deductible Home Health, Hospice, Outpatient Private Nurse 20% after deductible 40% after deductible Outpatient Rehab Therapy: Physical, Speech, Occupational $30 after deductible 40% after deductible ID-MPS 01/01/19 See other side for additional benefits None calendar year Covered 100% CITY OF BURLEY G1023316 1002 L70C0594 10/01/2019 MEMBER PAYMENT SUMMARY When using participating providers, you are responsible to pay the amounts in this column. When using nonparticipating providers, you are responsible to pay the amounts in this column. ---PAGE BREAK--- PARTICIPATING NONPARTICIPATING (In-Network) (Out-of-Network) SELECTHEALTH NETWORK MISCELLANEOUS SERVICES PARTICIPATING NONPARTICIPATING Durable Medical Equipment (DME)4 20% after deductible 40% after deductible Miscellaneous Medical Supplies (MMS)3 20% after deductible 40% after deductible Maternity4 See Professional, Inpatient or Outpatient 40% after deductible Cochlear Implants4 See Professional, Inpatient or Outpatient 50% after deductible Infertility - Select Services *50% after deductible *50% after deductible (Max Plan Payment $1,500/ calendar year; $5,000 lifetime) Donor Fees for Covered Organ Transplants 20% after deductible 50% after deductible TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime See Professional, Inpatient or Outpatient 50% after deductible OPTIONAL BENEFITS PARTICIPATING NONPARTICIPATING Mental Health and Chemical Dependency4 Office Visits $30 40% after deductible Inpatient 20% after deductible 40% after deductible Outpatient 20% 40% after deductible Residential Treatment2 20% after deductible 40% after deductible Chiropractic $30 (up to 15 visits per calendar year) *50% after deductible Injectable Drugs and Specialty Medications4 20% after deductible 40% after deductible PRESCRIPTION DRUGS Prescription Drug List (formulary) Prescription Drugs - Up to 30 Day Supply of Covered Medications 4 Tier 1 Tier 2 Tier 3 Tier 4 Maintenance Drugs - 90 Day Supply (Mail-Order, Retail90 ® )-selected drugs 4 Tier 1 Tier 2 Tier 3 Generic Substitution Required 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. * Not applied to Medical out-of-pocket maximum. ID-MPS 01/01/19 C selecthealth.org Benefits are administered and underwritten by SelectHealth, Inc. SM (domiciled in Utah). 07/30/19 difference between name brand and generic 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. All covered services obtained outside the United States, except for routine, urgent, or emergency conditions require preauthorization. To contact Member Services, call [PHONE REDACTED] 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. $100 $15 $60 $150 Generic required or must pay copay plus cost RxSelect® $15 $30 $50 CITY OF BURLEY G1023316 1002 L70C0594 10/01/2019 MEMBER PAYMENT SUMMARY