MEDICAL_DESKTOP

Medical

Full-time employees who actively work at least 30 hours per week are eligible for medical benefits, along with their legal spouse, dependent children up to age 26, and children of any age if they depend on the employee for support due to a disability. Coverage for new hires begins on the first of the month following their date of hire.

800-538-5038  |  www.selecthealth.org  |  Group #: G1021985

Home / Core Benefits / Medical

Employee Premiums

Medical premiums for both traditional and high-deductible health plans (HDHP) are based on your participation level and earned status in the wellness program. Please see the Wellness Program section of the website for more information.

Plan & Wellness Program Participation
Single (Per Pay Period)
Two-Party (Per Pay Period)
Family (Per Pay Period)
Traditional (Not Participating in Wellness Program
$86.00
$174.25
$245.00
Traditional (Participating in Wellness Program
$60.25
$122.00
$171.50
HDHP (Not Participating in Wellness Program)
$69.75
$141.50
$199.00
HDHP (Participating in Wellness Program)
$46.75
$95.00
$133.50
Plan & Wellness Program Participation

Traditional (Not Participating in Wellness Program)

Single (Per Pay Period): $83.50
Two-Party (Per Pay Period): $169.25
Family (Per Pay Period): $237.75

Traditional (Participating in Wellness Program)

Single (Per Pay Period): $59.75
Two-Party (Per Pay Period): $121.00
Family (Per Pay Period): $170.25

HDHP (Not Participating in Wellness Program)

Single (Per Pay Period): $66.50
Two-Party (Per Pay Period): $135.00
Family (Per Pay Period): $189.50

HDHP (Participating in Wellness Program)

Single (Per Pay Period): $45.00
Two-Party (Per Pay Period): $91.25
Family (Per Pay Period): $128.25

Plan Information

Stampin’ Up! offers two types of health plans: a traditional plan and a high-deductible health plan. It is up to you and your family to determine which plan is best suited for your healthcare needs.

Traditional Plan
In-Network Services from out-of-network providers are not covered (except emergencies)
EMPLOYEE-ONLY COVERAGE
Deductible
$750
Out-of-Pocket Maximum
$3,000
TWO-PARTY OR FAMILY COVERAGE
Deductible
$750 per person/$1,500 per family
Out-of-Pocket Maximum
$3,000 per person/$6,000 per family
INPATIENT SERVICES
Medical, Surgical, and Hospice
20% after deductible
Skilled Nursing Facility (Up to 60 days)
20% after deductible
Inpatient Rehab Therapy (Up to 40 days)
20% after deductible
Physician's Fees (medical, surgical, maternity, and anesthesia)
20% after deductible
PROFESSIONAL SERVICES
Primary Care Provider (PCP)
$25
Secondary Care Provider (PCP)
$40
Allergy Treatment and Serum
20%
Major Surgery
20%
Physician's Fees (Medical, Surgical, Maternity, Anesthesia)
20% after deductible
Preventive Services
Covered 100%
VISION SERVICES
Preventive Exams
Covered 100%
All Other Exams
$40
OUTPATIENT SERVICES
Outpatient Facility and Ambulatory Surgical
20% after deductible
Ambulance (Air or Ground emergencies only)
20% after deductible
Emergency Room (In Network)
$250 after deductible
Emergency Room (Out of Network)
$250 after deductible
Urgent Care Facilities
$50
Intermountain KidsCare Facilities
$25
Intermountain Connect Care
Covered 100%
Chemotherapy, Radiation, and Dialysis
20% after deductible
Diagnostic Tests (Minor)
Covered 100%
Diagnostic Tests (Major)
20% after deductible
Home Health, Hospice, and Outpatient Private Nurse
20% after deductible
Outpatient Rehab Therapy
$40 after deductible
MENTAL HEALTH AND CHEMICAL DEPENDENCY
Office VIsits
$25
Inpatient
20% after deductible
Outpatient
20%
Residential Treatment
20% after deductible
PRESCRIPTION DRUGS
Retail Pharmacy
Tier 1 / Tier 2 / Tier 3 / Tier 4
$15 / $30 / $50 / $100
Maintenance Drugs (90-Day, Mail-Order Supply)
Tier 1 / Tier 2 / Tier 3 / Tier 4
$15 / $60 / $150
Injectable Drugs and Specialty Medications
20% after deductible
High-Deductible Health Plan
In-Network Services from out-of-network providers are not covered (except emergencies)
EMPLOYEE-ONLY COVERAGE
Deductible
$2,000
Out-of-Pocket Maximum
$3,200
TWO-PARTY OR FAMILY COVERAGE
Deductible
$4,000
Out-of-Pocket Maximum
$3,200 per person/$6,000 per family
INPATIENT SERVICES
Medical, Surgical, and Hospice
20% after deductible
Skilled Nursing Facility (Up to 60 days)
20% after deductible
Inpatient Rehab Therapy (Up to 40 days)
20% after deductible
Physician's Fees
20% after deductible
PROFESSIONAL SERVICES
Primary Care Provider (PCP)
$15 after deductible
Secondary Care Provider (PCP)
$25 after deductible
Allergy Treatment and Serum
20% after deductible
Major Surgery
20% after deductible
Physician's Fees (Medical, Surgical, Maternity, Anesthesia)
20% after deductible
Preventive Services
Covered 100%
VISION SERVICES
Preventive Exams
Covered 100%
All Other Exams
$25 after deductible
OUTPATIENT SERVICES
Outpatient Facility and Ambulatory Surgical
20% after deductible
Ambulance (Air or Ground emergencies only)
20% after deductible
Emergency Room (In Network)
$75 after deductible
Emergency Room (Out of Network)
$75 after deductible
Urgent Care Facilities
$35 after deductible
Intermountain KidsCare Facilities
$15 after deductible
Intermountain Connect Care
Covered 100%
Chemotherapy, Radiation, and Dialysis
20% after deductible
Diagnostic Tests (Minor)
Covered 100% after deductible
Diagnostic Tests (Major)
20% after deductible
Home Health, Hospice, and Outpatient Private Nurse
20% after deductible
Outpatient Rehab Therapy
$25 after deductible
MENTAL HEALTH AND CHEMICAL DEPENDENCY
Office VIsits
$15 after deductible
Inpatient
20% after deductible
Outpatient
20% after deductible
Residential Treatment
20% after deductible
PRESCRIPTION DRUGS
Retail Pharmacy
Tier 1 / Tier 2 / Tier 3 / Tier 4
$7 AD* / $21 AD / $42 AD / $100 AD
Maintenance Drugs (90-Day, Mail-Order Supply)
Tier 1 / Tier 2 / Tier 3 / Tier 4
$7 AD / $42 AD / $126 AD
Injectable Drugs and Specialty Medications
20% after deductible

AD* (after deductible)

Please Note: Preauthorization is required for certain services. Benefits may be reduced or denied if you do not preauthorize certain services. Please refer to the Certificate of Coverage for details.

Please see the Member Payment Summary and Certificate of Coverage for each plan to fully understand coverage and the differences between the two plans. The information here is intended solely to provide you with a brief description of your benefit options. The specific provisions in our contract will govern any and all claims or coverage issues.

Network Information

Employees working in the Riverton office should use providers and facilities in the SelectHealth Share network. Due to the number of providers available in Kanab and the surrounding areas, employees working in the Kanab office should use providers in the larger SelectHealth Med network.

To find an in-network provider, go to https://selecthealth.org/find-a-doctor and select the appropriate network. It is your responsibility to confirm that a provider will accept SelectHealth insurance and is a member of the correct network when you make your appointment.

Intermountain Connect Care

Connect Care is another option for accessing convenient, high-quality urgent care whenever and wherever you need it. You can use your smartphone, tablet, or computer to connect with an Intermountain Healthcare clinician 24 hours a day, every day of the year.

Commonly treated conditions include stuffy and/or runny nose, allergies, sinus pain and pressure, eye infections, cough, painful urination, lower back pain, joint pain or strains, and minor skin problems.

You can create a Connect Care account and connect with a provider online or by downloading the app from the App Store or Google Play.

Cost of a Connect Care Consultation*
Traditional Plan
Covered 100%
High-Deductible Health Plan
$59 before deductible; Covered 100% after deductible.

*If the provider cannot diagnose your condition and states that you need to be seen in person, you will not be charged for the Connect Care visit.

Intermountain Health Answers

Health Answers is a nurse line that allows you to speak to a registered nurse who will listen to your concerns, answer medical questions, and help you decide what course of action to take. You can connect with a nurse 24 hours a day, every day of the year by calling 844-501-6600.

Resources

Summary of Benefits Coverage (All Plans)

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Share (Riverton) Member Payment Summary - HDHP

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Share (Riverton) Member Payment Summary - Traditional

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Med (Kanab) Member Payment Summary - HDHP

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Med (Kanab) Member Payment Summary - Traditional

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Intermountain Home Delivery Pharmacy

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Tellica Imaging

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Out of Area Care Options

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