Professional services of physicians

• In physician’s office, including minor surgical procedures
• Office medical consultations
• Second surgical opinion
• Advanced care planning
• Home visits

$15 per office visit to a primary care physician

$35 per office visit to a specialist

In an urgent care center

$35 Urgent care or Intermountain InstaCare visit

$15 Intermountain KidsCare visit

• During a hospital stay
• In a skilled nursing facility
• Private duty nursing

Note: Major surgery is a surgical procedure having one or more of the following characteristics: (A) performed within or upon the contents of the abdominal, pelvic, cranial or thoracic cavities; (B) typically requiring general anesthesia; (C) has a level of difficulty or length of time to perform which constitutes a hazard to life or function of an organ or tissue; or (D) requires the special training to perform. Any surgical procedure not classified as major surgery is considered a minor surgical procedure.

Note: Private duty nursing requires preauthorization from your Physician. See page (Applies to printed brochure only).

15% of the allowed amount after deductible

Applied behavior analysis (ABA)

Office visit services performed by a board-certified physician in neurology or pediatrics with experience in diagnosing autism spectrum disorder:

• Evaluation, management, and assessment services necessary to determine whether a member has an autism spectrum diagnosis

Behavior training, management, and ABA therapy services by certified therapists:

• Care rendered in the home or other clinical setting

Note: For information on physical/occupational/speech therapy benefits, see page (Applies to printed brochure only). For information on the mental health ABA benefits, see Section 5(e) Mental Health and Substance Use Benefits. See page (Applies to printed brochure only).

$15 per office visit to a primary care physician

$35 per office visit to a specialist

15% of the allowed amount after deductible for outpatient services

Urgent Care/Intermountain Connect Care telehealth services –

Intermountain Connect Care_^SM is a convenient way to talk to a provider about urgent medical issues, no appointment necessary. Use your smartphone, tablet, or computer to connect to a provider within minutes. Download the app or visit www.intermountainconnectcare.org to get started.

Providers at Connect Care can help you with:

• Cough
• Ear pain
• Eye infection
• Joint pain/strain
• Lower back pain
• Minor burns/rashes/skin infections
• Sinus pain/pressure
• Seasonal allergies
• Sore throat
• Urinary pain

Nothing, Deductible waiver applies to telehealth services

All non-urgent telehealth services - 

Telehealth services are covered in accordance with the SelectHealth Plan medical policy when rendered by a participating provider. (Deductible does not apply to telehealth services)

Nothing, Deductible waiver applies to telehealth services

Tests, such as: 

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine mammograms
• CAT Scans/MRI 
• Ultrasound
• Electrocardiogram and EEG

Note: Preauthorization is required for certain diagnostic testing. See page (Applies to printed brochure only).

Note: Major and minor diagnostic tests are based on several considerations such as the invasiveness and complexity of the test, the level of expertise required to interpret or perform the test, and where the test is commonly performed. If you have a question about the category of a particular test, please contact Member Services at 844-345-FEHB.

Nothing for minor diagnostic tests

15% of the allowed amount after deductible for major diagnostic tests

Injectable, implantable, and IV therapy drugs rendered in a provider's office or in a facility setting

Note: Preauthorization is required for certain injectable drugs and specialty medications. See page (Applies to printed brochure only). If you have questions about preauthorization requirements, please call Member Services at 844-345-FEHB.

30% of the allowed amount after deductible

Routine physical once every year

The following preventive services are covered at the time interval recommended at each of the links below.

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at
  https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
• Individual counseling on prevention and reducing health risks
• Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Woman preventive care services please visit the Health and Human Services (HHS) website at
  https://www.healthcare.gov/preventive-care-women/

Routine mammogram - covered for women

Nothing

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Nutritional therapy

Note: Medical nutritional therapy is a comprehensive nutrition service provided by dietitians with a state license or statutory certification.

Note: After the 5th visit, nutritional therapy is covered under the inpatient, outpatient, or office visit benefit, depending on where the therapy is rendered. See Section 5(a) Diagnostic and treatment services on page (Applies to printed brochure only). For questions regarding specific medical benefits, please contact Member Services at 844-345-FEHB.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member deductible, copayments and coinsurance.

Not covered:

• Physical exams and immunizations required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

• Well-child visits, examinations, and other preventive services as described in the Bright Futures Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DRaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the CDC website at https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the USPSTF online at https://www.uspreventiveservicestaskforce.org

Nothing

Nutritional therapy

Note: Medical nutritional therapy is a comprehensive nutrition service provided by dietitians with a state license or statutory certification.

Note: After the 5th visit, nutritional therapy is covered under the inpatient, outpatient, or office visit benefit, depending on where the therapy is rendered. See Section 5(a) Diagnostic and treatment services on page (Applies to printed brochure only). For questions regarding specific medical benefits, please contact Member Services at 844-345-FEHB.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member deductible, copayments and coinsurance.

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes for pregnant women
• Delivery
• Postnatal care

A single office visit copay of $15 when pregnancy is confirmed; nothing for subsequent prenatal or postpartum care

Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to preauthorize your vaginal or cesarean delivery; see page (Applies to printed brochure only) for other circumstances, such as extended stays for you or your baby.
• Deliveries rendered by a non-participating provider (whether inside or outside of the service area) will be denied unless the situation is deemed to be an urgent or emergency situation.
• You may remain in the hospital up to 48 hours after vaginal delivery and 96 hours after a or cesarean delivery. All non-routine obstetric admissions and maternity stays longer than 48 hours after a vaginal delivery and 96 hours after a cesarean delivery require preauthorization from your physician. We will extend your inpatient stay if medically necessary. See page (Applies to printed brochure only).
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Note: Childbirth in any place other than a Hospital or a participating birthing center connected to a Hospital either through a bridge, ramp, or adjacent to the labor and delivery unit is not covered. This includes all Provider and/or Facility charges related to the delivery.

Not covered:

• Home delivery

Contraceptive counseling on an annual basis

Nothing

A range of voluntary family planning services, limited to:

• Tubal ligation. See Section 5(b) Surgical procedures. See page (Applies to printed brochure only).
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo-Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit. Vasectomies, see Section 5(b). See page (Applies to printed brochure only).

Genetic testing:

• Prenatal testing when performed as part of an amniocentesis to assess specific chromosomal abnormalities in women at high risk for inheritable conditions that can lead to significant immediate and/or long-term health consequences to the child after birth:
• Neonatal testing for specific inheritable metabolic conditions (e.g. PKU)
• When the member has more than five-percent probability of having an inheritable genetic condition and has signs or symptoms suggestive of a specific condition or a strong family history of the condition (defined as two or more first-degree relatives with the condition) and results of the testing will directly affect the patient's treatment
• Pre-implantation embryonic genetic testing performed to identify an inherited genetic condition known to already exist in either parent's family which has the potential to cause serious and impactful medical conditions for the child

Note: Gene therapy and genetic testing requires preauthorization from your physician. See page (Applies to printed brochure only).

Note: Kymriah and Luxturna are covered for certain gene therapy treatments. Contact the Plan if you have a coverage question, please contact Member Services at 844-345-FEHB. See page (Applies to printed brochure only).

Note: Genetic counseling is covered when provided by a participating provider.

15% of the allowed amount after deductible

BRCA testing

Note: BRCA testing requires preauthorization from your physician.
See page (Applies to printed brochure only).

Nothing

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling services not shown as covered

All Charges

Infertility is a condition resulting from a disease (an interruption, cessation, or disorder of body functions, systems, or organs) of the male or female reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery.

Services for the diagnosis of infertility are only covered in limited circumstances, including fulguration of ova ducts, hysteroscopy, hysterosalpingogram, certain laboratory tests, diagnostic laparoscopy, and some imaging studies. For a full list of covered infertility services, please contact SelectHealth Plan.

Note: Infertility does not apply to the out-of-pocket maximum. Infertility coverage is limited to a maximum plan payment of $1,500 per calendar year.

50% of the allowed amount after deductible

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
  • In vitro fertilization (IVF)
  • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
  • Artificial insemination (AI), such as:
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI)
• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg
• Oncofertility
• Fertility drugs

• Testing

$15 copay to a primary care physician for testing

$35 copay to a specialist for testing

• Allergy treatment
• Allergy injections
• Allergy serum

15% of the allowed amount after deductible

Not covered:

• Certain allergy tests and treatments are not covered. Contact SelectHealth Plan Member Services for details.

• Chemotherapy and radiation therapy

Note: Certain radiation therapies and medical oncology drugs require preauthorization. See page (Applies to printed brochure only).

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed in Section 5(b).

• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

Note: Enteral formula requires preauthorization from your physician.
See page (Applies to printed brochure only).

• Growth hormone therapy (GHT)

Note: Growth hormone therapy is covered under the prescription drug benefit and requires preauthorization. See page (Applies to printed brochure only) and Section 5(f) Prescription Drug Benefits on page (Applies to printed brochure only).

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page (Applies to printed brochure only).

• Applied behavior analysis (ABA) - children with autism spectrum disorder

Note: For information on the mental health ABA benefits, see Section 5(e) Mental Health and Substance Use Disorder Benefits. See page (Applies to printed brochure only).

15% of the allowed amount after deductible

Cardiac rehabilitation following qualifying event/condition

Nothing, after deductible

Proton beam therapy in the following limited circumstances:

• Chordomas or chondrosarcomas arising at the base of the skull or along the axial skeleton without distant metastases;
• Other central nervous system tumors located near vital structures;
• Pituitaryneoplasms;
• Uveal melanomas confined to the globe (not distant metastases); or
• In accordance with SelectHealth Plan medical policy

15% of the allowed amount after deductible

Not covered:

• Neutron beam therapy
• Proton beam therapy, except as shown above.

All charges

Services rendered by one of the following:

• Qualified physical therapist
• Occupational therapist

Note: We only cover therapy when a provider:

• orders the care;
• identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed.

Note: Outpatient physical and occupational therapy requires preauthorization from your provider after 10 visits. See page (Applies to printed brochure only).

Note: Vision therapy services require preauthorization. See page (Applies to printed brochure only).

Note: Inpatient therapy coverage is limited to 40 days per calendar year for all therapy types combined and requires preauthorization. See page (Applies to printed brochure only).

Note: For information on the mental health ABA benefits, see Section 5(e) Mental Health and Substance Use Disorder Benefits on page (Applies to printed brochure only).

$35 per office visit

$35 per outpatient visit

15% of the allowed amount after deductible per visit during covered inpatient admission

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• Services for functional nervous disorders

Speech therapy visits

Note: We only cover therapy when a provider:

• Orders the care;
• Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• Indicates the length of time the services are needed.

Note: Outpatient speech therapy requires preauthorization from your provider after 10 visits. See page (Applies to printed brochure only).

Note: Inpatient therapy coverage is limited to 40 days per calendar year for all therapy types combined. See page (Applies to printed brochure only).

Note: For information on the mental health ABA benefits, see Section 5(e) Mental Health and Substance Use Disorder Benefits on page (Applies to printed brochure only).

$35 per office visit

$35 per outpatient visit

15% of the allowed amount after deductible per visit during covered inpatient admission

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

Note: For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care, children.

Note: For coverage of external hearing aids and implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants, see Section 5(a) Orthopedic and prosthetic devices.

$15 per office visit to a primary care provider

$35 per office visit to a specialist

Nothing for preventive visit

Nothing for minor diagnostic tests

15% of the allowed amount after deductible for major diagnostic tests

Not covered:

• Hearing services that are not shown as covered

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)
• Annual eye refractions

Note: See Preventive care, children for eye exams for children.

$15 per office visit to a primary care physician

$35 per office visit to a specialist

Nothing for preventive visits

15% of the allowed amount after deductible for covered vision aids

Not covered:

• Eyeglasses or contact lenses, except as shown above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

$15 per office visit to a primary care physician

$35 per office visit to a specialist

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

• Artificial limbs and eyes
• Prosthetic sleeve or sock 
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Orthotics and other corrective appliances for the foot are covered if part of a lower foot brace and they are prescribed as part of a specific treatment associated with recent, related surgery 
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy

Note: Artificial limbs (prosthetics) require preauthorization from your physician. See page (Applies to printed brochure only).

Note: TMJ coverage is limited to $2,000 per person per calendar year.

Note: We will only cover cochlear implants, BAHA and related services and supplies that we determine are medically necessary. We only cover these services when we preauthorize the treatment. See page (Applies to printed brochure only).

Note: For information on the professional charges for the surgery to insert the implant, see Section 5(b) Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services Provided by a Hospital or Other Facility, and Ambulance Services.

15% of the allowed amount after deductible

• External hearing aids for children up to age 22 per calendar year
• External hearing aids for adults age 22 and over every 3 calendar years

Any amount over $2,500 after deductible

Not covered:

• Orthotics and other corrective appliances for the foot are not covered unless part of a lower foot brace and they are prescribed as part of a specific treatment associated with recent, related surgery
• Lumbosacralsupports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic replacements provided less than 5 years after the last one we covered

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs (custom or motorized*)
• Crutches
• Walkers
• Audible prescription reading devices
• Speech generating devices
• Blood glucose monitors
• Insulin pumps*
• Wound vac*

* Note: These items require preauthorization from your physician. Continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and DME items with a purchase price over $5,000 also require preauthorization. See page (Applies to printed brochure only).

Note: Call us at 844-345-FEHB as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

15% of the allowed amount after deductible

Not covered:

Batteries are not covered unless when used to power:

• A wheelchair 
• An insulin pump for treatment of diabetes

• Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse
  (L.V.N.), or home health aide
• Services include oxygen therapy, intravenous therapy and medications

Note: Home health requires preauthorization from your physician.
See page (Applies to printed brochure only).

15% of the allowed amount after deductible

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative

Chiropractic coverage is limited to 20 visits per calendar year.

• Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Note: Chiropractic benefits are administered through the American Specialty Health (ASH) network. ASH provides claims adjudication, member service, and appeals services for chiropractic claims. Access to ASH chiropractors is based on medical necessity. Members with questions regarding ASH benefits, eligibility, or participating providers can contact the ASH Member Services department at 800-678-9133. A directory of providers who participate with ASH can be found at www.selecthealth.org/fehb or www.ashcompanies.com.

$35 per visit

No benefit

 Coverage is provided for:

• Tobacco Cessation programs, including individual, group, phone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence.

Nothing for 4 Tobacco Cessation counseling sessions per quit attempt and 2 quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

$15 office visit to a primary care physician

$35 office visit to a specialist

• Diabetes self management education
• Childhood obesity education
• Asthma education

A comprehensive range of services, such as:

• Operative procedures
• Vasectomy
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures 
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment for morbid obesity (bariatric surgery)
• Insertion of internal prosthetic devices. See 5(a) Orthopedic and prosthetic devices for device coverage information
• Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay hospital benefits for a pacemaker and surgery benefits for insertion of the pacemaker. 

Note: Major surgery is a surgical procedure having one or more of the following characteristics: (A) performed within or upon the contents of the abdominal, pelvic, cranial or thoracic cavities; (B) typically requiring general anesthesia; (C) has a level of difficulty or length of time to perform which constitutes a hazard to life or function of an organ or tissue; or (D) requires the special training to perform. Any surgical procedure not classified as major surgery is considered a minor surgical procedure.

Note: Preauthorization is required for some surgical procedures. See page (Applies to printed brochure only) for details on which procedures require preauthorization.

$15 per office visit to a primary care physician for minor surgery

$35 per office visit to a specialist for minor surgery

15% of the allowed amount after deductible for major surgery

Tubal ligation

Nothing

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • The condition produced a major effect on the member's appearance and
  • The condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • Surgery to produce a symmetrical appearance of breasts
  • Treatment of any physical complications, such as lymphedemas
  • Breast prostheses and surgical bras and replacements (see Prosthetic devices)
• Surgeries related to gender reassignment
  • Breast implantation/augmentation
  • Orchiectomy
  • Penectomy
  • Vaginoplasty
  • Clitoroplasty
  • Labiaplasty
  • Subcutaneous mastectomy
  • Hysterectomy
  • Salpingo-oophorectomy
  • Vaginectomy
  • Metoidioplasty
  • Scrotoplasty
  • Urethroplasty
  • Placement of testicular prostheses
  • Phalloplasty

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Note: Gender reassignment surgery requires preauthorization from your physician. For questions regarding specific covered surgical procedures, please contact Member Services at 844-345-FEHB. See page (Applies to printed brochure only).

15% of the allowed amount after deductible

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury 
  • The following gender reassignment procedures: Abdominoplasty, blepharoplasty, brow lift, cheek/malar implants, chin/nose implants, collagen injections, facial bone reconstruction, face lift, forehead lift, calf lift, hair removal/hairplasty including medications that cause hair loss or growth, hair transplantation, lip reduction, liposuction, mastopexy, neck tightening, pectoral implants, reduction thyroid chondroplasty, rhinoplasty, voice modification surgery, & voice therapy/lessons

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Other surgical procedures that do not involve the teeth or their supporting structures
• Temporomandibular joint disorders (TMJ)

Note: TMJ coverage is limited to $2,000 per person per calendar year.

$15 per office visit to a primary care physician

$35 per office visit to a specialist

15% of the allowed amount after deductible for a major office surgery

15% of the allowed amount after deductible for physician’s fees 

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

These solid organ transplants are covered. Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas

Note: Organ transplants take place in an inpatient setting and require preauthorization. See page (Applies to printed brochure only).

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

Note: Organ transplants take place in an inpatient setting and require preauthorization. See page (Applies to printed brochure only).

Blood or marrow stem cell transplants 

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Multiple myeloma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Note: Organ transplants take place in an inpatient setting and require preauthorization. See page (Applies to printed brochure only).

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. 

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

Note: Organ transplants take place in an inpatient setting and require preauthorization. See page (Applies to printed brochure only).

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence and if approved by the Plan’s medical director in accordance with the Plan’s protocols. 

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for
  • Beta Thalassemia Major
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Myelodysplasia/Myelodysplastic Syndromes
• Autologous Transplants for
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Aggressive non-Hodgkin's lymphoma
  • Breast Cancer
  • Childhood rhabdomyosaucoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)

Note: Organ transplants take place in an inpatient setting and require preauthorization. See page (Applies to printed brochure only).

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

15% of the allowed amount after deductible for physician’s fees

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

Professional services provided in:

• Hospital (inpatient)
• Hospital (outpatient)
• Skilled nursing facility
• Ambulatory surgical center

Note: Certain pain management services require preauthorization from your physician. See page (Applies to printed brochure only).

15% of the allowed amount after deductible for physician’s fees

Professional services provided in:

• Office

Note: Certain pain management services require preauthorization from your physician. See page (Applies to printed brochure only).

$15 per office visit to a primary care physician

$35 per office visit to a specialist

15% of the allowed amount for a major office surgery

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

15% of the allowed amount after deductible per admission

Maternity and delivery

• You do not need to preauthorize your normal delivery. You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. All non-routine obstetric admissions and maternity stays longer than 48 hours after a regular delivery and 96 hours after a cesarean delivery require preauthorization from your physician. We will extend your inpatient stay if medically necessary. See page (Applies to printed brochure only).
• Deliveries rendered by a non-participating provider (whether inside or outside of the service area) will be denied unless the situation is deemed to be an urgent or emergency situation.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Professional services are covered under Section 5(a) and Section 5(b).

Note: Childbirth in any place other than a Hospital or a participating birthing center connected to a Hospital either through a bridge, ramp, or adjacent to the labor and delivery unit is not covered. This includes all Provider and/or Facility charges related to the delivery.

$200 per admission

Other hospital services and supplies, such as:

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory test and X-rays
• Dressing, splints, cases, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetists services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Note: Inpatient admissions require preauthorization from your physician. See page (Applies to printed brochure only).

15% of the allowed amount after deductible

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

15% of the allowed amount after deductible

Not covered: 

• Platelet rich plasma or other blood derived therapies for orthopedic procedures.

Skilled nursing is covered up to 60 days per calendar year

Skilled nursing is only covered when services cannot be provided adequately through a home health program.

Note: All admissions to facilities, including rehabilitation, transitional care, skilled nursing, and all routine hospitalizations require preauthorization from your physician. See page (Applies to printed brochure only).

15% of the allowed amount after deductible per admission

Not covered: 

• Custodial care

Hospice care is supportive care provided on an inpatient or outpatient basis to a terminally ill member not expected to live more than six months.

Note: Hospice care requires preauthorization from your physician.
See page (Applies to printed brochure only).

15% of the allowed amount after deductible per admission

Not covered:

• Independent nursing, homemaker services, custodial care

15% of the allowed amount after deductible

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctors’ services

Note: If you are admitted inpatient during an emergency room (ER) visit, the ER copay will be waived. Instead, Inpatient Hospital benefits will apply.

Note: Intermountain KidsCare Clinics are owned by Intermountain Healthcare, and provide after hours urgent care services for pediatric patients. The clinic does not accept primary care patients.

Note: The Instacare clinic is an Intermountain Healthcare urgent care clinic for patients of all ages. Also see Section 5(a) for Telehealth urgent care services.

$35 Urgent care or Intermountain InstaCare visit

$15 Intermountain KidsCare visit

$200 per visit Emergency Room Copay after deductible

Not covered: 

• Elective care or non-emergency care

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctors’ services

Note: If you are admitted inpatient during an emergency room (ER) visit, the ER copay will be waived. Instead, Inpatient Hospital benefits will apply.

Note: Intermountain KidsCare Clinics are owned by Intermountain Healthcare, and provide after hours urgent care services for pediatric patients. The clinic does not accept primary care patients.

Note: The Instacare clinic is an Intermountain Healthcare urgent care clinic for patients of all ages. Also see Section 5(a) for Telehealth urgent care services.

$35 Urgent care or Intermountain InstaCare visit

$15 Intermountain KidsCare visit

$200 per visit Emergency Room Copay after deductible

Not covered: 

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside of the service area

Professional ambulance service (including air ambulance) when medically appropriate.

Note: See Section 5(c) for non-emergency service.

15% of the allowed amount after deductible

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual, single-family, multi-family, or group therapy visits)
• Diagnosis and treatment of alcoholism and drug use, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy
• ABA therapy

Note: Inpatient and residential treatment require preauthorization from your physician. See page (Applies to printed brochure only).

Note: For benefit information on the diagnostic and treatment services as well as ABA-related therapy, see Section 5(a) Medical Services and Supplies Provided by Physicians and other Health Care Professionals. See page (Applies to printed brochure only).

$15 per office visit

15% of the allowed amount after deductible for inpatient or outpatient services

Telehealth services are covered in accordance with the SelectHealth Plan medical policy when rendered by a participating provider. (Deductible does not apply to telehealth services)

Nothing (deductible does not apply to telehealth services)

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

Note: Inpatient and residential treatment admissions require preauthorization from your physician. See page (Applies to printed brochure only).

$15 per office visit

15% of the allowed amount after deductible for outpatient

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

Note: Inpatient and residential treatment admissions require preauthorization from your physician. See page (Applies to printed brochure only).

15% of the allowed amount after deductible per inpatient admission

Outpatient services provided and billed by a hospital or other covered facility

• Services in approved treatment programs, such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment

$15 per office visit

15% of the allowed amount after deductible for outpatient

Methadone maintenance, associated clinics or services

$15 per office visit to a primary care physician

$35 per office visit to a specialist

15% of the allowed amount after deductible for inpatient or outpatient services

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered. 
• Growth hormone therapy (GHT)
• Insulin
• Diabetic supplies:
  • Disposable needles and syringes for the administration of covered medications
  • Continuous glucose monitors
• Drugs for sexual dysfunction

Note: Selected prescription drugs and supplies require preauthorization from your physician as referenced on page (Applies to printed brochure only). Contact SelectHealth Plan for information on a specific drug(s) as requirements may change due to new drugs, therapies, or other factors.

Note: Drugs for sexual dysfunction are limited; contact SelectHealth Plan for more details on covered sexual dysfunction drugs.

Note: GHT is only covered when a prior authorization has been approved for the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page (Applies to printed brochure only).

Note: Preauthorization and deductibles do not apply to Naloxone-based rescue agents. A Tier 1 copay applies for a 30-day or 90-day timeframe.

Prescription Medications
Tier 1  $5
Tier 2  $40 after deductible
Tier 3  50% of the allowed amount up to a $250 maximum, after deductible
Tier 4  30% of the allowed amount after deductible

Mail Order
Maintenance Medications - 90 day supply
Tier 1  $5 
Tier 2  $80 after deductible
Tier 3  50% of the allowed amount after deductible

Note: If there is no generic equivalent available, you will still have to pay the brand name copay. 

Women's contraceptive drugs and devices:

• Generic oral contraceptives on our formulary list
• Generic emergency contraception, including OTC when filled with a prescription
• Generic injectable contraceptives on our formulary list - five (5) vials per calendar year
• Diaphragms - one (1) per calendar year
• Generic patch contraception

Nothing

The following are covered: 

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 and 800 mcg
• Liquid iron supplements for children age 6 months - 1 year
• Vitamin D supplements (prescription strength) (400 and 1000 units) for members 65 or older
• Prenatal vitamins for pregnant women
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
• Statin for adults aged 40-75 years with no history of cardiovascular disease (CVD), 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater

Note: Preventive Medications with a USPSTF recommendations of A or B are covered without cost-share when prescribed by a health care professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to
www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations.

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for urgent and/or emergencies out-of-area
• Fertility drugs
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them except as required by the Affordable Care Act
• Nonprescription medications medicines
• Prescriptions dispensed in a provider’s office are not covered unless expressly approved by SelectHealth Plan

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco and nicotine dependence are covered under the Tobacco Cessation benefit. See page (Applies to printed brochure only).

All charges

We cover restorative services and supplies necessary to promptly repair and/or replace sound natural teeth. The need for these services must result from an accidental injury. 

Note: Major surgery is a surgical procedure having one or more of the following characteristics: (A) performed within or upon the contents of the abdominal, pelvic, cranial or thoracic cavities; (B) typically requiring general anesthesia; (C) has a level of difficulty or length of time to perform which constitutes a hazard to life or function of an organ or tissue; or (D) requires the special training to perform. Any surgical procedure not classified as major surgery is considered a minor surgical procedure.

$15 per office visit to a primary care physician, including minor office surgery

$35 per office visit to a specialist, including minor office surgery

$35 Urgent care or Intermountain Instacare visit

$200 emergency room after deductible

15% of the allowed amount after deductible for a major office surgery

15% of the allowed amount after deductible for physician’s fees 

Professional services, such as:

• Routine physicals
• Routine screenings
• Routine immunizations endorsed by the Centers for Disease Control and Prevention (CDC)
• Routine prenatal care
• Tobacco cessation programs
• Obesity weight loss programs
• Disease management programs

Nothing

Routine physical once every year

The following preventive services are covered at the time interval recommended at each of the links below.

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at
  https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
• Individual counseling on prevention and reducing health risks
• Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Woman preventive care services please visit the Health and Human Services (HHS) website at
  https://www.healthcare.gov/preventive-care-women/

Nothing

Routine mammogram - covered for women

Nothing

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Nothing

• Routine exams limited to:
  • One routine eye exam every 12 months
  • One routine hearing exam every 12 months

Nothing

Nutritional therapy

Note: Medical nutritional therapy is a comprehensive nutrition service provided by dietitians with a state license or statutory certification.

Note: After the 5th visit, nutritional therapy is covered under the impatient, outpatient, or office visit benefit, depending on where the therapy is rendered. For questions regarding specific medical benefits, please contact Member Services at 844-345-FEHB.

Nothing

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

Well-child visits examinations and immunizations as described in the Bright Future Guidelines provided by the American Academy of Pediatrics

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive listing of services will be subject to the applicable member copayments and coinsurance.

Note: A complete list of preventive care services recommended under the U.S. Preventive Task Force (USPSTF) is available online at www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

HHS: www.healthcare.gov/preventive-care-benefits/

CDC: www.cdc.gov/vaccines/schedules/index.html 

For additional information: www.healthfinder.gov/myhealthfinder/default.aspx

Note: For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to brightfutures.aap.org/Pages/default.aspx

Nothing

Nutritional therapy

Note: Medical nutritional therapy is a comprehensive nutrition service provided by dietitians with a state license or statutory certification.

Note: After the 5th visit, nutritional therapy is covered under the inpatient, outpatient, or office visit benefit, depending on where the therapy is rendered. For questions regarding specific medical benefits, please contact Member Services at 844-345-FEHB.

Nothing

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

The deductible applies to almost all benefits in this Section. In the You Pay column, we say "No deductible" when it does not apply. When you receive covered services from network providers, you are responsible for paying the allowable charges until you meet the deductible.

100% of allowable charges until you meet the deductible of $1,500 per person, $3,000 per Self Plus One enrollment or $3,000 per Self and Family enrollment.

After you meet the deductible, we pay the allowable charge (less your coinsurance or copayment) until you meet the annual catastrophic out-of-pocket maximum.

In-network: After you meet the deductible, you pay the indicated coinsurance or copayments for covered services. You may choose to pay the coinsurance and copayments from your HSA or HRA, or you can pay for them out-of-pocket.

Professional services of physicians

• In physician's office
• Office medical consultations
• Second surgical opinion
• Advanced care planning
• Home visits

$10 per office visit to a primary care physician

$30 per office visit to a specialist

• In an urgent care center

Note: The Instacare clinic is an Intermountain Healthcare urgent care clinic for patients of all ages.

Note: KidsCare clinics are owned by Intermountain Healthcare and provide after-hours urgent care services for pediatric patients. The clinic does not accept primary care patients.

$30 Urgent care or Intermountain Instacare visit

$10 Intermountain KidsCare visit

• During a hospital stay
• In a skilled nursing facility
• Private duty nursing

Note: Private duty nursing requires preauthorization from your Physician. See page (Applies to printed brochure only).

Nothing

$150 for outpatient facility services

$150 per day up to $750 per admission for inpatient facility services

Applied behavior analysis (ABA)

Office visit services performed by a board-certified physician in neurology or pediatrics with experience in diagnosing autism spectrum disorder:

• Evaluation, management, and assessment services necessary to determine whether a member has an autism spectrum diagnosis

Behavior training, management, and ABA therapy services by certified therapists:

• Care rendered in the home or other clinical setting

Note: For information on physical/occupational/speech therapy benefits, see page (Applies to printed brochure only). For information on the mental health ABA benefits, see Section 5(e) Mental Health and Substance Use Benefits.

$10 per office visit to a primary care physician

$30 per office visit to a specialist

Urgent Care/Intermountain Connect Care telehealth services – 

Intermountain Connect Care is a convenient way to talk to a provider about urgent medical issues, no appointment necessary. Use your smartphone, tablet, or computer to connect to a provider within
minutes. Download the app or visit www.intermountainconnectcare.org to get started.

Provider at Connect Care can help you with:

• Cough
• Ear pain
• Eye infection
• Joint pain/strain
• Lower back pain
• Minor burns/rashes/skin infections
• Sinus pain/pressure
• Seasonal allergies
• Sore throat
• Urinary pain

Nothing, Deductible waiver applies to telehealth services

All non-urgent telehealth services –

Telehealth services are covered in accordance with the SelectHealth Plan medical policy when rendered by a participating provider. (Deductible does not apply to telehealth services)

Nothing, Deductible waiver applies to telehealth services

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine mammograms
• CAT scans/MRI
• Ultrasound
• Electrocardiogram and EEG

Note: Preauthorization is required for certain diagnostic testing. See page (Applies to printed brochure only).

Note: Major and minor diagnostic tests are based on several considerations such as the invasiveness and complexity of the test, the level of expertise required to interpret or perform the test, and where the test is commonly performed. If you have a question about the category of a particular test, please contact Member Services at 844-345-FEHB.

Nothing for minor diagnostic tests

$150 for major diagnostic tests

Injectable, implantable, and IV therapy drugs rendered in a provider's office or in a facility setting.

Note: Preauthorization is required for certain injectable drugs and specialty medications (even when Medicare is your primary insurance). See (Applies to printed brochure only). If you have questions about preauthorization requirements, please call Member Services at 844-345-FEHB.

30% of the allowed amount

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Delivery
• Postnatal care

A single office visit copay of $20 when pregnancy is confirmed; nothing for subsequent prenatal or postpartum care.

Screening for gestational diabetes for pregnant women

Nothing

Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to preauthorize your vaginal or cesarean delivery; see page (Applies to printed brochure only) for other circumstances, such as extended stays for you or your baby.
• Deliveries rendered by a non-participating provider (whether inside or outside of the service area) will be denied unless the situation is deemed to be an urgent or emergency situation.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. All non-routine obstetric admissions and maternity stays longer than 48 hours after a vaginal delivery and 96 hours after a cesarean delivery require preauthorization from your physician. We will extend your inpatient stay if medically necessary. See page (Applies to printed brochure only).
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Note: Childbirth in any place other than a Hospital or a participating birthing center connected to a Hospital either through a bridge, ramp, or adjacent to the labor and delivery unit is not covered. This includes all Provider and/or Facility charges related to the delivery.

Nothing

Not covered:

• Home delivery

All charges

Contraceptive counseling on an annual basis

Nothing

A range of voluntary family planning services, limited to:

• Tubal ligation. See Section 5(b) Surgical procedures on page (Applies to printed brochure only). 
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo-Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit. Vasectomies, see Section 5(b) on page (Applies to printed brochure only).

Nothing

Genetic testing:

• Prenatal testing when performed as part of an amniocentesis to assess specific chromosomal abnormalities in women at high risk for inheritable conditions that can lead to significant immediate and/or long-term health consequences to the child after birth:
• Neonatal testing for specific inheritable metabolic conditions (e.g. PKU)
• When the member has more than five-percent probability of having an inheritable genetic condition and has signs or symptoms suggestive of a specific condition or a strong family history of the condition (defined as two or more first-degree relatives with the condition) and results of the testing will directly affect the patient's treatment
• Pre-implantation embryonic genetic testing performed to identify an inherited genetic condition known to already exist in either parent's family which has the potential to cause serious and impactful medical conditions for the child

Note: Gene therapy and genetic testing requires preauthorization from your physician. See page (Applies to printed brochure only).

Note: Genetic counseling is covered when provided by a participating provider.

Nothing for professional fees

$150 copay

BRCA testing

Note: BRCA testing requires preauthorization from your physician. See page (Applies to printed brochure only).

Nothing

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling services not shown as covered

All charges

Infertility is a condition resulting from a disease (an interruption, cessation, or disorder of body functions, systems, or organs) of the male or female reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery.

Services for the diagnosis of infertility are only covered in limited circumstances, including fulguration of ova ducts, hysteroscopy, hysterosalpingogram, certain laboratory tests, diagnostic laparoscopy, and some imaging studies. For a full list of covered infertility services, please contact SelectHealth Plan.

Note: Infertility does not apply to the out-of-pocket maximum.
Infertility coverage is limited to a maximum plan payment of $1,500 per calendar year.

50% of allowed amount

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
  • In vitro fertilization (IVF)
  • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
  • Artificial insemination (AI), such as:
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI)
• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg
• Oncofertility
• Fertility drugs

All charges

• Testing

$10 per office visit to a primary care physician for testing

$30 per office visit to a specialist for testing

• Allergy treatment
• Allergy injections
• Allergy serum

$100 copay

Not covered:

• Certain allergy tests and treatment are not covered. Contact SelectHealth Plan Member Services for details.

All charges

• Chemotherapy and radiation therapy

Note: Certain radiation therapies and medical oncology drugs require preauthorization. See page (Applies to printed brochure only).

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed in Section 5(b) on page (Applies to printed brochure only).

• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

Note: Enteral formula requires preauthorization from your physician. See page (Applies to printed brochure only).

• Growth hormone therapy (GHT)

Note: Growth hormone therapy is covered under the prescription drug benefit and requires preauthorization. See page (Applies to printed brochure only) and Section 5(f) Prescription Drug Benefits on page (Applies to printed brochure only).

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page (Applies to printed brochure only).

• Applied behavior analysis (ABA) - Children with autism spectrum disorder

Note: For information on the mental health ABA benefits, see Section 5(e) Mental Health and Substance Use Disorder Benefits. See page (Applies to printed brochure only).

$150 per day

Cardiac rehabilitation following qualifying event/condition

Nothing

Proton beam therapy in the following limited circumstances:

• Chordomas or chondrosarcomas arising at the base of the skull or along the axial skeleton without distant metastases;
• Other central nervous system tumors located near vital structures;
• Pituitaryneoplasms;
• Uveal melanomas confined to the globe (not distant metastases); or
• In accordance with SelectHealth Plan medical policy

$150 per day

Not covered:

•  Neutron beam therapy
•  Proton beam therapy, except as shown above

All charges

Services rendered by one of the following:

• Qualified physical therapist
• Occupational therapist

Note: We only cover therapy when a provider:

• orders the care;
• identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed.

Note: Outpatient physical and occupational therapy require preauthorization from your provider after 10 visits. See page (Applies to printed brochure only).

Note: Vision therapy services require preauthorization. See page (Applies to printed brochure only).

Note: Inpatient therapy coverage is limited to 40 days per calendar year for all therapy types combined.

Note: For information on the mental health ABA benefits, see Section 5(e) Mental Health and Substance Use Disorder Benefits. See page (Applies to printed brochure only).

$30 per office visit

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• Services for functional nervous disorders  

All charges

Speech therapy visits

Note: We only cover therapy when a provider:

• orders the care;
• identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed.

Note: Outpatient speech therapy requires preauthorization from your provider after 10 visits. See page (Applies to printed brochure only).

Note: Inpatient therapy coverage is limited to 40 days per calendar year for all therapy types combined.

Note: For information on the mental health ABA benefits, see Section 5(e) Mental Health and Substance Use Disorder Benefits. See page (Applies to printed brochure only).

$30 per office visit

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

Note: For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care, children.

Note: For coverage of external hearing aids and implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants, see Section 5(a) Orthopedic and prosthetic devices.

$10 per office visit to a primary care physician

$30 per office visit to a specialist

Nothing for preventive visits

Not covered:

• Hearing services that are not shown as covered

All charges

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)
• Annual eye refractions

Note: See Preventive care, children for eye exams for children.

$10 per office visit to a primary care physician

$30 per office visit to a specialist

Nothing for preventive visits

Not covered:

• Eyeglasses or contact lenses, except as shown above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

All charges

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

$10 per office visit to a primary care physician

$30 per office visit to a specialist

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges

• Artificial limbs and eyes
• Prosthetic sleeve or sock 
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Orthotics and other corrective appliances for the foot are covered if part of a lower foot brace and they are prescribed as part of a specific treatment associated with recent, related surgery 
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy

Note: Artificial limbs (prosthetics) require preauthorization from your physician. See page (Applies to printed brochure only).

Note: TMJ coverage is limited to $2,000 per person per calendar year.

Note: We will only cover cochlear implants, BAHA and related services and supplies that we determine are medically necessary. We only cover these services when we preauthorize the treatment. See page (Applies to printed brochure only).

Note: For information on the professional charges for the surgery to insert the implant, see Section 5(b) Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services Provided by a Hospital or Other Facility, and Ambulance Services.

Nothing for professional fees

• External hearing aids for children up to age 22 per calendar year
• External hearing aids for adults age 22 and over every 3 calendar years

Any amount over $2,500

Not covered:

• Orthotics and other corrective appliances for the foot are not covered unless part of a lower foot brace and they are prescribed as part of a specific treatment associated with recent, related surgery
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Prosthetic replacements provided less than 5 years after the last one we covered

All charges

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs (custom or motorized*)
• Crutches
• Walkers
• Audible prescription reading devices
• Speech generating devices
• Blood glucose monitors
• Insulin pumps*
• Wound vac*

* Note: These items require preauthorization from your physician. Continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and DME items with a purchase price over $5,000 also require preauthorization. See page (Applies to printed brochure only).

Note: Call us at 844-345-FEHB as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Nothing for professional fees

5% of the allowed amount

Not covered:

Batteries are not covered unless when used to power:

• A wheelchair 
• An insulin pump for treatment of diabetes

All charges

• Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide
• Services include oxygen therapy, intravenous therapy and medications

Note: Home health requires preauthorization from your physician. See page (Applies to printed brochure only).

$150 per day

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative

All charges

Chiropractic coverage is limited to 20 office visits per calendar year.

• Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Note: Chiropractic benefits are administered through the American Specialty Health (ASH) network. ASH provides claims adjudication, member service, and appeals services for chiropractic claims. Access to ASH chiropractors is based on medical necessity. Members with questions regarding ASH benefits, eligibility, or participating providers can contact ASH Member Services at 800-678-9133. A directory of providers who participate with ASH can be found at
www.selecthealth.org/fehb or www.ashcompanies.com.

$30 per office visit

No benefit

All charges

Coverage is provided for:

• Tobacco cessation programs, including individual, group, phone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence.

Nothing for 4 tobacco cessation counseling sessions per quit attempt and 2 quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

• Diabetes self management education
• Childhood obesity education
• Asthma education

Nothing

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures 
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment for morbid obesity (bariatric surgery)
• Insertion of internal prosthetic devices. See 5(a) Orthopedic and prosthetic devices for device coverage information
• Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay hospital benefits for a pacemaker and surgery benefits for insertion of the pacemaker. 

Note: Preauthorization is required for some surgical procedures. See page (Applies to printed brochure only) for details on which procedures require preauthorization.

Nothing

Vasectomy

Professional fees: Nothing

Inpatient facility: $150 per day up to $750 per admission

Outpatient facility: $150 copay

Tubal ligation

Nothing

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if: 
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • Surgery to produce a symmetrical appearance of breasts
  • Treatment of any physical complications, such as lymphedemas
  • Breast prostheses and surgical bras and replacements (see Prosthetic devices)
• Surgeries related to gender reassignment
  • Breast implantation/augmentation
  • Orchiectomy
  • Penectomy
  • Vaginoplasty
  • Clitoroplasty
  • Labiaplasty
  • Subcutaneous mastectomy
  • Hysterectomy
  • Salpingo-oophorectomy
  • Vaginectomy
  • Metoidioplasty
  • Scrotoplasty
  • Urethroplasty
  • Placement of testicular prostheses
  • Phalloplasty

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. 

Note: Gender reassignment surgery requires preauthorization from your physician. See page (Applies to printed brochure only). For questions regarding specific covered surgical procedures, please contact Member Services at 844-345-FEHB. 

Nothing

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury
  • The following gender reassignment procedures: abdominoplasty, blepharoplasty, brow lift, cheek/malar implants, chin/nose implants, collagen injections, facial bone reconstruction, face lift, forehead lift, calf lift, hair removal/hairplasty including medications that cause hair loss or growth, hair transplantation, lip reduction, liposuction, mastopexy, neck tightening, pectoral implants, reduction thyroid chondroplasty, rhinoplasty, voice modification surgery, & voice therapy/lessons

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Other surgical procedures that do not involve the teeth or their supporting structures
• Temporomandibular joint disorders (TMJ)

Note: TMJ coverage is limited to $2,000 per person per calendar year.

$10 per office visit to a primary care physician

$30 per office visit to a specialist

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

All charges

These solid organ transplants are covered. Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
• Isolated small intestine
• Small intestine with the liver
• Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas

Note: Organ transplants take place in an inpatient setting and require preauthorization. See page (Applies to printed brochure only).

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for
• AL Amyloidosis
• Multiple myeloma (de novo and treated)
• Recurrent germ cell tumors (including testicular cancer)

Note: Organ transplants take place in an inpatient setting and require preauthorization. See page (Applies to printed brochure only).

Blood or marrow stem cell transplants 

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for
• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Acute myeloid leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced Myeloproliferative Disorders (MPDs)
• Advanced neuroblastoma
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Hemoglobinopathy
• Leukocyte adhesion deficiencies
• Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
• Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
• Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
• Myelodysplasia/Myelodysplastic syndromes
• Paroxysmal Nocturnal Hemoglobinuria
• Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
• Severe combined immunodeficiency
• Severe or very severe aplastic anemia
• Sickle cell anemia
• X-linked lymphoproliferative syndrome
• Autologous transplants for
• Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Breast Cancer
• Epithelial ovarian cancer
• Ewing’s sarcoma
• Multiple myeloma
• Neuroblastoma
• Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Note: Organ transplants take place in an inpatient setting and require preauthorization. See page (Applies to printed brochure only).

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. 

• Allogeneic transplants for
• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Acute myeloid leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced Myeloproliferative Disorders (MPDs)
• Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Hemoglobinopathy
• Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
• Myelodysplasia/Myelodysplastic syndromes
• Paroxysmal Nocturnal Hemoglobinuria
• Severe combined immunodeficiency
• Severe or very severe aplastic anemia
• Autologous transplants for
• Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Neuroblastoma

Note: Organ transplants take place in an inpatient setting and require preauthorization. See page (Applies to printed brochure only).

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence and if approved by the Plan’s medical director in accordance with the Plan’s protocols. 

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for
• Beta Thalassemia Major
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Multiple myeloma
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin’s lymphoma
• Chronic lymphocytic leukemia
• Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
• Chronic myelogenous leukemia
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Multiple myeloma
• Myelodysplasia/Myelodysplastic Syndromes
• Autologous Transplants for
• Advanced childhood kidney cancers
• Advanced Ewing sarcoma
• Aggressive non-Hodgkin's lymphoma
• Breast Cancer
• Childhood rhabdomyosaucoma
• Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
• Chronic myelogenous leukemia
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Epithelial Ovarian Cancer
• Mantle Cell (Non-Hodgkin lymphoma)

Note: Organ transplants take place in an inpatient setting and require preauthorization. See page (Applies to printed brochure only).

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

Nothing 

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

All charges

Professional services provided in:

• Hospital (inpatient)
• Hospital (outpatient)
• Skilled nursing facility
• Ambulatory surgical center

Note: Certain pain management services require preauthorization from your physician. See page (Applies to printed brochure only).

Nothing

Professional services provided in:

• Office

Note: Certain pain management services require preauthorization from your physician. See page (Applies to printed brochure only).

$10 per office visit to a primary care physician

$30 per office visit to a specialist

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$150 per day up to $750 per admission

Maternity and delivery

• You do not need to preauthorize your normal delivery. You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. All non-routine obstetric admissions and maternity stays longer than 48 hours after a regular delivery and 96 hours after a cesarean delivery require preauthorization from your physician. We will extend your inpatient stay if medically necessary. See page (Applies to printed brochure only).
• Deliveries rendered by a non-participating provider (whether inside or outside of the service area) will be denied unless the situation is deemed to be an urgent or emergency situation.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Professional services are covered under both Sections 5(a) and 5(b).

Note: Childbirth in any place other than a Hospital or a participating birthing center connected to a Hospital either through a bridge, ramp, or adjacent to the labor and delivery unit is not covered. This includes all Provider and/or Facility charges related to the delivery.

$100 per admission

Other hospital services and supplies, such as:

• Operating, recovery and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory test and X-rays
• Administration of blood, blood plasma, and other biologicals
• Pre-surgical testing
• Dressing, splints, cases, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetists services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Note: Inpatient admissions require preauthorization from your physician. See page (Applies to printed brochure only).

$150 per day up to $750 per admission

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds

All charges

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

$150 per day

Not covered: 

• Platelet rich plasma or other blood derived therapies for orthopedic procedures.

All charges

Skilled nursing is covered up to 60 days per calendar year

Skilled nursing is only covered when services cannot be provided adequately through a home health program.

Note: All admissions to facilities, including rehabilitation, transitional care, skilled nursing, and all routine hospitalizations require preauthorization from your physician. See page (Applies to printed brochure only).

$150 per day up to $750 per admission

Not covered:

• Custodial care

All charges

Hospice care is supportive care provided on an inpatient or outpatient basis to a terminally ill member not expected to live more than six months.

Note: Hospice care requires preauthorization from your physician. See page (Applies to printed brochure only).

$150 per day for outpatient facility services

$150 per day up to $750 per admission for inpatient facility services

Not covered:

• Independent nursing, homemaker services

All charges

Local professional ambulance service when medically appropriate

$100 copay

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctors’ services

Note: If you are admitted inpatient during an emergency room (ER) visit, the ER copay will be waived. Instead, Inpatient Hospital benefits will apply.

Note: Intermountain KidsCare Clinics are owned by Intermountain Healthcare, and provide after hours urgent care services for pediatric patients. The clinic does not accept primary care patients.

Note: The Instacare clinic is an Intermountain Healthcare urgent care clinic for patients of all ages. Also see Section 5(a) for Telehealth urgent care services.

$30 Urgent care or Intermountain InstaCare visit

$10 Intermountain KidsCare visit

$200 per visit Emergency Room Copay

Not covered: 

• Elective care or non-emergency care

All charges

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctors’ services

Note: If you are admitted inpatient during an emergency room (ER) visit, the ER copay will be waived. Instead, Inpatient Hospital benefits will apply.

Note: Intermountain KidsCare Clinics are owned by Intermountain Healthcare, and provide after hours urgent care services for pediatric patients. The clinic does not accept primary care patients.

Note: The Instacare clinic is an Intermountain Healthcare urgent care clinic for patients of all ages. Also see Section 5(a) for Telehealth urgent care services.

$30 Urgent care or Intermountain InstaCare visit

$10 Intermountain KidsCare visit

$200 per visit Emergency Room Copay

Not covered: 

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside of the service area

All charges

Professional ambulance service (including air ambulance) when medically appropriate.

Note: See Section 5(c) for non-emergency service.

$100 copay

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual, single-family, multi-family, or group therapy visits)
• Diagnosis and treatment of alcoholism and drug use, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy
• ABA therapy

Note: Inpatient and residential treatment admissions require preauthorization from your physician. See page (Applies to printed brochure only).

Note: For benefit information on the diagnostic and treatment services as well as ABA-related therapy, see Section 5(a) Medical Services and Supplies Provided by Physicians and other Health Care Professionals.