Individual Member Guide

UTAH 2018 SELECTHEALTH HEALTHSAVE® 2 CHOOSE A PLAN Most HealthSaveSM plans are designed to be paired with a Health Savings Account (HSA). With a HealthSave plan, We offer plans by metal tiers—Bronze, Silver, or Gold. you have more control over your healthcare dollars. Some These levels are defined onhealthcare.gov and indicate HealthSave plans are cost-share reduction plans; however, how much you’ll spend on benefits. We also offer a not all cost-share reduction plans are eligible for an HSA. Catastrophic plan.

WHAT IS AN HSA? Choosing a Plan That’s Right for You BRONZE An HSA is similar to a personal savings account, with a few differences. For HSA-eligible individuals, The health plan pays 60% on average. money contributed to an HSA is tax-exempt and You pay about 40%. can be used for certain medical expenses (as EXPANDED BRONZE defined by the IRS) such as deductibles, copays, We offer a variety of plan designs and networks to fit your needs and budget. As you The health plan pays 65% on average. and coinsurance. Our preferred HSA vendor is You pay about 35%. HealthEquity®. Please visit healthequity.com for shop, it’s important to understand how our plans are categorized. Follow these four more information about an HSA. SILVER steps to help you enroll on the plan that's right for you. The health plan pays 70% on average. You pay about 30%. New! GOLD The health plan pays 80% on average. SELECTHEALTH HEALTHSAVE REWARDS Follow these four steps 1 FIND OUT IF YOU QUALIFY You pay about 20%. We believe that engaged members live their healthiest lives to find the perfect plan: possible, and healthy members help us keep insurance FOR A TAX CREDIT OR Catastrophic coverage plans pay CATASTROPHIC: premiums low. If you are looking for a plan that rewards COST-SHARE REDUCTION less than 60% of the total average cost of care. FIND OUT IF YOU QUALIFY you for making healthy choices, our HealthSave Rewards 1 FOR A TAX CREDIT ADVANCED PREMIUM TAX CREDIT ESTIMATOR plan (on the Select Value® network) may be just the right fit. The plan subscriber can receive an annual payment of If you qualify for a subsidy, the federal government $100—in the form of a Visa gift card—for fulfilling a few CHOOSE A PLAN will pay a portion of your monthly premium. Visit TRADITIONAL PLANS 2 commitments, such as creating a My Health account, selecthealth.org/applyonline and enter some simple Traditional plans are a popular choice for those who'd choosing a Primary Care Physician (PCP), and filling out an information, including family size and household income, CHOOSE A NETWORK like a traditional or "classic" plan, including coverage for online health assessment.* Members who enroll on this plan 3 to see if you qualify and get an estimate. medical services, preventive care, and prescription drugs. must earn and redeem their reward by December 31, 2018. Choose a deductible and benefits that work for you. MAKE YOUR FIRST PAYMENT COST-SHARE REDUCTION *Rewards made available subject to program terms Some of these plans have a deductible waiver or a 4 In addition to a tax credit, you may be eligible for cost- and conditions. limited deductible waiver for Primary Care, Mental sharing reduction plans that lower the amount you pay Health, and Specialty Care office visits. On these plans, out of pocket for deductibles, coinsurance, and copays. the deductible only applies for some or a limited number Members of a federally recognized American Indian tribe CATASTROPHIC PLAN of office visits. may also qualify for additional cost-sharing benefits. If you are younger than age 30, or if you qualify for a hardship exemption, you may consider purchasing a catastrophic health plan. These plans have lower premiums, higher deductibles and out-of-pocket maximums, making them ideal for those who only want protection from very high medical costs. These plans are not eligible for a premium subsidy.

2 selecthealth.org selecthealth.org 3 PARTICIPATING HOSPITALS AND CLINICS

VALUE MED Alta View Hospital* American Fork Hospital* 10 PARTICIPATING HOSPITALS Intermountain Medical Center* 5,100+ PARTICIPATING PHYSICIANS & PROVIDERS LDS Hospital* McKay-Dee Hospital* Orem Community Hospital* Primary Children’s Hospital* Riverton Hospital* TOSH - The Orthopedic Specialty Hospital* Utah Valley Hospital* Bear River Valley Hospital* Delta Community Hospital* Dixie Regional Medical Center* Choosing a Network That’s Right for You River Road Campus Dixie Regional Medical Center* Fillmore Community Hospital* Garfield Memorial Hospital* Heber Valley Medical Center* Logan Regional Hospital* Park City Hospital* 3 CHOOSE A NETWORK Sanpete Valley Hospital* Sevier Valley Hospital* Our integration with Intermountain Healthcare® gives you access to high-quality hospitals, clinics, and doctors in the Cedar City Hospital* state. We offer two provider networks: Select Value and Select Med®. With Select Value, you generally enjoy lower Ashley Valley Medical Center premiums, but with Select Med you will have a larger network, giving you access to more providers. You can search for Beaver Valley Hospital participating providers at selecthealth.org/find-a-doctor, where you can also find patient satisfaction and quality 35 PARTICIPATING HOSPITALS Central Valley Medical Center ratings for many providers and clinics. 6,900+ PARTICIPATING PHYSICIANS & PROVIDERS Davis Hospital & Medical Center Franklin County Medical Center* LOWER COST HIGHER COST Gunnison Valley Hospital Huntsman Cancer Hospital FEWER PROVIDERS MORE PROVIDERS (For Med: Cancer Treatment Only) Kane County Hospital Milford Valley Memorial Hospital Moab Regional Hospital Mountain West Medical Center San Juan Hospital

Value – Serving the Wasatch Front, this network is highly Med – Our most popular network covers all of Utah Uintah Basin Medical Center integrated with Intermountain Healthcare and includes and includes 35 participating hospitals and more than Cassia Regional Hospital** 10 participating hospitals and more than 5,100 providers. 6,900 providers. Portneuf Medical Center* St. Luke’s Rehab Hospital - IP Acute Care Unit

*Idaho Facility

*Intermountain-owned Facility

4 selecthealth.org selecthealth.org 5 4 MAKE YOUR FIRST PAYMENT Visit selecthealth.org/applyonline to use our convenient MEMBER SERVICES QUESTIONS? online application. The application must be completed Our Member Services Call us. and signed electronically. If you need help with your representatives are application, call Individual Sales at 855-442-0220, or you available six days a week can call your agent. to answer questions about your benefits and claims. You’ll need to make your first month’s payment before To contact Member Services, call 800-538-5038 you will receive an ID card. Care Options weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m. TTY ALL YOUR INFO IN ONE PLACE users, please call 711.

Once enrolled, you’ll have access to My Health. Here you’ll NEED HELP SHOPPING FOR A PLAN? Before scheduling an appointment, consider the following care options. have important health and benefit information at your We’re happy to help you find the right plan. They could save you money and a trip to the doctor! fingertips—whenever and wherever you need it. We also Call your agent, or contact our Individual Sales provide a number of health resources, including LiVe Well team at 855-442-0220. INTERMOUNTAIN HEALTH ANSWERS® EMERGENCY CARE tools, to help you achieve your wellness goals. Call Intermountain Health Answers to speak to a In emergencies, you should call 911 or go to the nearest registered nurse who will listen to your concerns, answer hospital. Though copays are the same at all emergency any medical questions you may have, and help you rooms, you will save money by visiting participating decide what course of action to take. Call 844-501-6600. hospitals. View participating facilities on page 5 of this booklet or visit . Free! selecthealth.org/find-a-doctor See your benefits on the next page for more information. INTERMOUNTAIN CONNECT CARE®

Intermountain Connect Care is a fast, convenient OUTSIDE THE STATE OF UTAH way to talk to a provider about urgent medical If you have an emergency or need urgent care outside of issues. Use your smartphone, tablet, or computer Utah, participating benefits apply to services received in a to connect to a provider within minutes. It’s easier doctor’s office, urgent care facility, or emergency room. than you may think—download the app or visit You may save money on out-of-area services by using intermountainconnectcare.org to get started. Multiplan or PHCS providers and facilities. To find one, call or visit . $10 copay before deductible for non-HealthSave 800-678-7427 multiplan.com plans; $10 copay after deductible for HealthSave See your benefits on the next page for more information. (HSA Qualified) plans.

INTERMOUNTAIN INSTACARE®/KIDSCARE® SELECTHEALTH MEMBER ADVOCATES® They’re open late—and are a great choice for SelectHealth Member Advocates can help you find sore throats, broken bones, sprains, headaches, a doctor or schedule an appointment. stomachaches, earaches, and other urgent medical Call 800-515-2220 weekdays, from 7:00 a.m. to conditions. With nearly 40 locations, there’s a site near 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m. you. Use our app to reserve your spot in line!

See your benefits on the next page for more information.

6 selecthealth.org selecthealth.org 7 Preauthorization is required for certain services. This chart is not a complete list of benefits. If you have questions, visit selecthealth.org or call Member Services at 800-538-5038.

Standard Catastrophic SelectHealth HealthSave3, 4 Benchmark1 Deductible Limited Office Visit Waiver2 No Deductible for Office Visits 2018 Bronze 6650 - Bronze 6650 Expanded Bronze Expanded Bronze Expanded Bronze Silver 4000 - Silver 2250 UTAH PLAN Catastrophic 7350 Rewards (Value Only) (Med Only) 3175 Silver 3100 Bronze 6350 2450 Silver 1800 Bronze 6700 4600 - Copay Copay Silver 2500 (Off Exchange Only) Gold 1500

Deductible

Single $7,350 $6,650 $6,650 $3,175 $3,100 $6,350 $2,450 $1,800 $6,700 $4,600 $4,000 $2,500 $2,250 $1,500

Family $14,700 $13,3003 $13,3003 $6,3503 $6,2003 $12,700 $4,900 $3,600 $13,400 $9,200 $8,000 $5,000 $4,500 $3,000

Out-of-Pocket Max

Single $7,350 $6,650 $6,650 $6,650 $6,650 $7,350 $7,350 $7,350 $7,350 $7,350 $7,350 $7,350 $7,350 $6,000

Family $14,700 $13,3004 $13,3004 $13,3004 $13,3004 $14,700 $14,700 $14,700 $14,700 $14,700 $14,700 $14,700 $14,700 $12,000 $35 for first 3 PCP and/ $50 for first 3 $35 for first 3 Primary Care or mental health office 100% after $25 after $25 after $50 after $35 after $35 after 100% after deductible visits, then $50 visits, then $35 $25 $35 $35 $25 Provider (PCP) visits, then covered deductible deductible deductible deductible deductible deductible after deductible after deductible 100% after deductible

Secondary Care 100% after $40 after $40 after $65 after $60 after $60 after $65 after $60 after 100% after deductible 100% after deductible $60 $60 $60 $40 Provider (SCP) deductible deductible deductible deductible deductible deductible deductible deductible

Preventive Care Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% and Immunizations

Minor Diagnostic 100% after 100% after 100% after 100% after 100% after 100% after 100% after 100% after 100% after 100% after deductible 100% after deductible Covered 100% Covered 100% Covered 100% Tests deductible deductible deductible deductible deductible deductible deductible deductible deductible

$550 per day $550 per day Inpatient Hospital 100% after 30% after 20% after 40% after 50% after 50% after 40% after 50% after 20% after 100% after deductible 100% after deductible after deductible after deductible 50% after deductible Services deductible deductible deductible deductible deductible deductible deductible deductible deductible (up to five days) (up to five days)

Outpatient 100% after 30% after 20% after 40% after 50% after 50% after 40% after 40% after 30% after 50% after 20% after 100% after deductible 100% after deductible 50% after deductible Services deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible

100% after $600 after $600 after $600 after $600 after $600 after $600 after $600 after $600 after $600 after $600 after $350 after Emergency Room 100% after deductible 100% after deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible

Rx Deductible Medical and Rx Combined $1,000 $1,000 $1,000 $1,250 $2,500 $2,500 $1,000 $1,000 $500 Per Person

100% after $15 after $15 after Tier 1 Drugs 100% after deductible 100% after deductible $20 $15 $15 $20 $25 $25 $15 $15 $15 deductible deductible deductible

25% after 25% after 25% after 30% after $45 after $45 after 25% after 25% after 100% after 25% after 25% after 25% after pharmacy Tier 2 Drugs 100% after deductible 100% after deductible pharmacy pharmacy pharmacy pharmacy pharmacy pharmacy pharmacy pharmacy deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible 50% after 50% after 50% after 50% after $55 after $55 after 50% after 50% after 100% after 50% after 50% after 50% after pharmacy Tier 3 Drugs 100% after deductible 100% after deductible pharmacy pharmacy pharmacy pharmacy pharmacy pharmacy pharmacy pharmacy deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible 50% after 50% after 50% after 50% after 50% after 40% after 50% after 30% after 100% after 40% after 30% after 50% after pharmacy Tier 4 Drugs 100% after deductible 100% after deductible pharmacy pharmacy pharmacy pharmacy pharmacy pharmacy pharmacy pharmacy deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible

1 Benchmark plans cover only Essential Health Benefits (EHBs) as defined by the state of Utah. Some non-EHBs like prosthetics and 3 When two or more are enrolled on a HealthSave plan, only the family deductible applies. crutches are not covered under these plans. For more information, call Individual Sales at 855-442-0220 or visit healthcare.gov. 4 When two or more are enrolled, no single person in a family will pay more than the single out-of-pocket maximum. 2 The deductible is waived for the first threePrimary Care Provider and Mental Health office visits combined per year. Each of these three visits is subject to a copay only. Starting with the fourth visit, the deductible and copay will apply.

DEFINITIONS

DEDUCTIBLE COINSURANCE COPAY OUT-OF-POCKET MAXIMUM PRESCRIPTION (RX) DEDUCTIBLE PRESCRIPTION (RX) COPAY An amount a member must An amount that is calculated A fixed amount that members An amount a member will pay A separate deductible that only The fixed dollar amount members pay to providers or facilities as a percentage of the allowed must pay for covered services to for services covered by the applies to prescription drug pay for certain tiers of drugs. before the plan begins to amount for a service. For providers or facilities. plan. Amounts paid toward the coverage. Members must pay pay for eligible charges. example, a member pays deductible, coinsurance, and copays this amount before their plan 30% and the plan pays 70%. apply to the out-of-pocket maximum. begins to pay for prescriptions. 8 selecthealth.org selecthealth.org 9 PREVENTIVE CARE SELECTHEALTH ONLINE CHAT

Regular wellness exams can help HEALTHY BEGINNINGS® Get answers without picking up the you maintain optimal health. We Our prenatal care program provides phone. Chat is an easy way to ask provide educational information, emotional support and coaching for quick questions about your benefits, reminder calls, and mailings to expectant mothers from a team of such as: help you schedule the appropriate nurse care managers. In addition to >> How much of my deductible exams, immunizations, and tests pregnancy education materials and has been met? to detect and treat concerns early. other over-the-phone screenings, >> Has SelectHealth received a claim from my doctor? Most preventive care is covered the program includes high-risk care >> Am I covered for a 100 percent. For more information management when needed. preventive visit? about preventive care, visit Discover the SelectHealth Experience >> When is my original effective selecthealth.org/stayhealthy. date? Is my plan still in effect? >> How do I order replacement ID cards? >> Is my medication covered? Make the most of your plan—learn more about our member tools, programs, If so, how? and discounts. Visit selecthealth.org and log in to My Health. Click the SelectHealth link and scroll down—you’ll see a link to Chat with Us. We can’t wait to hear from you! MEDICAL COST ESTIMATOR SELECTHEALTH WEBSITE MY HEALTH

We make it easy to budget for Your health plan information is With My Health you'll have important medical costs: No phone calls, now even easier to access with our health and benefit information at codes, or math necessary. Here’s redesigned SelectHealth website. your fingertips 24/7. We also provide SELECTHEALTH MOBILE APP SELECTHEALTH MEMBER MEMBER DISCOUNTS how it works: Find plan documents, answers to a number of health resources, ADVOCATES® 1. Log in to the SelectHealth section frequently asked questions, doctors/ including online LiVe WellSM tools Log in to our mobile app to view We know that embracing a healthy of My Health; choose Medical facilities, and more by visiting the that can help you achieve your benefits and claims or search for Whether you need help with lifestyle is easier when it costs less. Cost Estimator. all new selecthealth.org. wellness goals. Log in to take your doctors and hospitals. Check year- behavioral or physical health, As a SelectHealth member, you will SM 2. Search by service, doctor, Health Assessment and start taking to-date totals for deductibles and Member Advocates can help have access to discounts on everyday or hospital. steps to improve your health. out-of-pocket maximums; look up you find the right care for your products and services that aren't 3. View a snapshot: You Pay, Plan pharmacies and medications; and needs. They can help you find the generally covered by your plan. Pays, Total Cost. view, email, or fax images of your closest provider and even schedule 4. Break it down by provider cost, The process is simple—no enrollment ID card to your doctor. Available an appointment. facility cost, labs, supplies, and forms, fees, or payroll deductions—just more. Refine your search to on Google Play™ and in the Call 800-515-2220 for help. great savings when you mention you include a geographic range or Apple® App StoreSM. sort by cost. are a SelectHealth member and show your ID card. For more information, Try our most-requested member visit selecthealth.org/discounts. tool: Visit selecthealth.org and log in to My Health to get started.

10 selecthealth.org selecthealth.org 11 Your Prescription Benefits

All of our Individual medical plans include prescription drug benefits, with access to more than 45,000 pharmacies nationwide.

PRESCRIPTION DRUGS It applies to drugs that you have been using for at least one month and expect to continue using for the next Coverage is divided into four tiers (levels). Each drug is year. Your member responsibility (e.g., copay or covered under a specific tier that corresponds to a copay coinsurance amounts) may be lower when you fill or coinsurance amount—this is the amount you pay. prescriptions using the 90-day benefit. Drugs on lower tiers may provide the treatment you need at the best value. There are two ways to fill a 90-day prescription: A local pharmacy that participates in our Retail90® Tier 1 – Lowest cost (mostly generic drugs) program (search for Retail90 pharmacies online) or Tier 2 – Higher cost (generic and brand-name drugs) the Intermountain Home Delivery Pharmacy Tier 3 – Highest cost (mostly brand-name drugs) (intermountainrx.org).

Tier 4 – Highest cost (Injectable drugs and ONLINE TOOLS specialty medications) It’s easy to view your family’s prescription history or find PRESCRIPTION DRUG out how much a drug will cost. Log in to My Health at LIST (PDL) selecthealth.org to access these useful pharmacy tools:

Individual plans use our RxCore® PDL. Search for your >> Review drug coverage. Use the search tool to see drug on our website (see Pharmacy) to find the tier and what drugs are covered under your prescription any special requirements. You will receive a copy of the drug list. You can use this feature even without a PDL with your member materials, but the online drug My Health account by going to the Pharmacy lookup is the most complete, current PDL. Benefits page under the Pharmacy tab at selecthealth.org. Your prescription drug coverage is SPECIAL REQUIREMENTS listed by tier for both 30-day (retail) and 90-day Some drugs require step therapy or preauthorization (maintenance) prescriptions. before they will be covered by your plan. >> View claims. When you fill a prescription, the drug name, date filled, and total cost will be listed here. Step Therapy – If your drug requires step therapy, your doctor must first prescribe an alternative drug. These >> Compare drug prices. Use our drug lookup to find are generally more cost effective and do not compromise out how much your prescription will cost and view lower-cost alternatives. This feature will also clinical quality. Step therapy may be waived for indicate if the drug has special requirements. medical necessity. >> Find a pharmacy. Search for a participating Preauthorization – This means that your doctor must pharmacy by location. We are contracted with most contact us for approval before your drug will be covered. major chains and many privately owned pharmacies.

90-DAY MAINTENANCE DRUG BENEFIT >> Check for drug interactions. Avoid the unwanted side effects or reduced effectiveness that can occur The 90-day maintenance drug benefit allows you to if two drugs you are taking interact with one another. obtain a 90-day supply of certain generic medications.

12 selecthealth.org selecthealth.org 13 SelectHealth Dental®

SelectHealth Dental provides comprehensive coverage to keep your teeth healthy. With hundreds of providers to choose from, top-ranked customer service, and online General Medical Information support, there’s plenty to smile about.

TRADITIONAL PLAN

You must see participating providers on your SelectHealth Dental network. A buy-up option gives you access to non OUR PLANS EXCESS CHARGES participating dentists. Our plans are designed to provide coverage for hospital, These are charges from providers and facilities that FUNDAMENTAL PRIME CLASSIC medical, preventive care, and surgical expenses incurred exceed the SelectHealth allowed amount for covered 500+ PARTICIPATING PROVIDERS 600+ PARTICIPATING PROVIDERS 1,600+ PARTICIPATING PROVIDERS as a result of a covered accident or illness. Coverage is services. You are responsible to pay for excess charges The Fundamental network is our The Prime network is our midsized The Classic network is our largest and provided through participating providers for daily from nonparticipating providers and facilities. These smallest but most affordable network. option, providing affordability with most popular plan. It is a statewide hospital room and board, miscellaneous hospital charges do not apply to your out-of-pocket maximum. It provides the greatest value to more access to dental providers. It network that extends into northern and services, anesthesia services, in-hospital medical members seeking dental care along extends throughout the Wasatch Front southern Utah, and provides coverage services, and out-of-hospital care. Coverage is subject NONCOVERED SERVICE IN CONJUNCTION WITH the Wasatch Front. to service members in the most in rural areas where Prime and A COVERED SERVICE populated counties. Fundamental are not available. to any deductible, copay provisions, or other limitations that may be set forth in your Contract. When a noncovered service is performed as part of the same operation or process as a covered service, only the ELIGIBILITY covered service charges will be considered. Allowed You and your dependents may apply for coverage if you amounts may be calculated and fairly divided to exclude are a resident of Utah and not eligible for Medicare. any charges related to the noncovered service. Eligible dependents include the insured’s legal spouse, children younger than age 26, eligible disabled children APPEALS/ UTILIZATION MANAGEMENT (UM) older than age 26, and children who are under court- For information about what requires preauthorization, our ordered legal guardianship until legal guardianship ends. care management programs, or how to file an appeal, see See your Contract for more details on guardianship. your member materials or visit our Member Resources page selecthealth.org/policy. TERMINATION

Your coverage will not terminate (end) for health reasons. However, your coverage may end according to the terms SelectHealth complies with applicable Federal civil

Nonparticipating Nonparticipating of your contract, including any of these reasons: rights laws and does not discriminate on the basis Benefits Participating Participating (Optional) (Optional) >> Nonpayment of premiums of race, color, national origin, age, disability, or sex. Deductible $50/150 $50/150 $50/150 $50/150 >> Fraud or intentional misrepresentation of material fact ATENCIÓN: Si habla español, tiene a su disposición (Individual/Family) servicios gratuitos de asistencia lingüística. Llame Annual Maximum Plan Payment Options (Individual) $750 or $1,000 $750 or $1,000 $1,500 $1,500 >> You no longer reside, live, or work in the service area a SelectHealth: 1-800-538-5038 (TTY: 711). Preventive and Diagnostic (No waiting period) 20% after 10% after 30% after No charge If we do not receive a premium or we are unable to Oral exams, cleanings, fluoride, X-rays deductible deductible deductible collect a premium, you will be notified. 注意：如果您使用繁體中文，您可以免費獲得 Basic 20% after 40% after 30% after 50% after 語言援助服務。請致電 SelectHealth: (Six-month waiting period without prior coverage) deductible deductible deductible deductible Fillings and oral surgery EXCLUDED SERVICES 1-800-538-5038 (TTY: 711). Major 50% after 60% after 50% after 60% after (12-month waiting period without prior coverage) Certain services are not covered by your plan. For a list deductible deductible deductible deductible Crowns, bridges, dentures, endodontics, and periodontics of excluded services, see your member materials or visit selecthealth.org/exclusions. 14 selecthealth.org selecthealth.org 15 We’re committed to helping you stay healthy by providing access to high-quality healthcare at an affordable cost, giving superior service, and offering the tools you need to make smart decisions. For more information about our health plan options for individuals, contact our Individual Sales department at 855-442-0220. It all starts with one good choice.