We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, disability leave, pensions, etc., you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family.  If you have a Self and Family enrollment, you may contact us to add a family member. 

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) – such as marriage, divorce, or the birth of a child – outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren). 

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you in Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2023 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2022 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage with your new plan.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy). 

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-insurance/healthcare/plan-information/. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment. 

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-538-5038 or visit our website at
www.selecthealth.org. 

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 844-345-FEHB or write to us at   P.O. Box 30192 Salt Lake City, UT 84130-0192. You may also request replacement cards through our website at www.selecthealth.org/myhealth.

You can receive care from “Plan providers” and “Plan facilities.” You will only pay a deductible (if applicable), copayments, and/or coinsurance based on your benefit plan selection. If you are on our Standard POS Option, you can also get care from non-Plan providers or facilities, but it will cost you more. You can receive covered services from a participating provider without a required referral from your primary care provider or by another participating provider in the network. Services rendered by non-participating providers are not covered under the HDHP Option, unless they are urgent and/or emergency related.

FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

Plan providers are physicians and other healthcare professionals in or out of our service area that we contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website at www.selecthealth.org/fehb.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides care coordinators for complex conditions and can be reached at 800-442-5305 for assistance.   

Plan facilities are hospitals and other facilities in or out of our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website at www.selecthealth.org/fehb.

Your network includes SelectHealth Med® providers in Utah. To receive highest benefits, you must use doctors, clinics, and hospitals that participate in your network. Services received from non-participating providers are not covered for HDHP Option enrollees, with the exception of urgent and emergency care. If you need access to primary care, specialty care, Mental Health/Chemical Dependency, or Hospital services, call SelectHealth Member Advocates at 800-515-2220, or visit  www.selecthealth.org/fehb. A copy of the Provider and Facility Directory is available upon request. You can also find the most current list of Providers online. Visit https://selecthealth.org/find-a-doctor. 

You and each family member may choose a primary care provider, though one is not required. Your primary care provider can provide or arrange for most of your health care. 

Your primary care provider can be a Family Practitioner, Internal Medicine Doctor, Pediatrician, Obstetrician or Gynecologist (OB/GYN). Your primary care provider will provide most of your healthcare, or give you a referral to see a specialist.

If you want to change primary care provider or if your primary care provider leaves the Plan and you need help finding a new one, Member Advocates can help you find the right care for your needs. Call 800-515-2220 weekdays, from 7 a.m. to 8 p.m., and Saturdays, from 9 a.m. to 2 p.m.

You may see a specialist for needed care.

Here are some things you should know about specialty care:

• If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call us and we will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause;
  • drop out of the FEHB Program and you enroll in another FEHB program plan; or
  • reduce our service area and you enroll in another FEHB plan;

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days. 

Participating providers will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call Member Services immediately at 844-345-FEHB. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment. 

Preauthorization is prior approval from SelectHealth, Inc. for certain services. Obtaining preauthorization does not guarantee coverage. Your benefits for the preauthorized services are subject to the eligibility requirements, limitations, exclusions and all other provisions of the Plan.

Participating providers and facilities are responsible for obtaining preauthorization on your behalf; however, you should verify that they have obtained preauthorization prior to receiving services. 

Members are required to obtain prior approval for services rendered by a non-participating provider. Without an approved preauthorization, services will be denied. 

The following services require preauthorization:

• Advanced imaging including magnetic resonance imaging (MRI), computerized tomography (CT) scans, positron emission tomography (PET) scans, and cardiac imaging;
• All admissions to facilities, including rehabilitation, transitional care, skilled nursing, residential treatment centers, and all hospitalizations that are not for urgent or emergency conditions
• All non-routine obstetrics admissions, maternity stays longer than two days for a normal delivery or longer than four days for a cesarean section, and deliveries rendered by a non-participating provider (whether inside or outside of the service area) unless the situation is deemed to be an urgent or emergency situation;
• Home healthcare (except Skilled Nursing Visits), Hospice care and private duty nursing;
• Hospital level care at home;
• Bariatric surgery;
• Gender reassignment surgeries;
• Joint replacement;
• Surgeries on vertebral bodies, vertebral joints, spinal discs;
• Pain management/pain clinic services;
• All services obtained outside of the United States unless for an urgent condition, or an emergency condition;
• Gene therapy and certain genetic testing, including BRCA testing;
• Certain ultrasounds;
• Certain vein procedures;
• Certain radiation therapies;
• Certain sleep studies;
• Certain medical oncology drugs;
• Continuous glucose monitors;
• Hysterectomy;
• Tonsillectomy;
• Adenoidectomy;
• Vision rehabilitation therapy;
• Outpatient rehabilitation and habilitative therapy services after 20 visits;
• The following durable medical equipment (DME):
  • Insulin pumps
  • Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP);
  • Prosthetics (except eye prosthetics)
  • Negative pressure wound therapy electrical pump (wound vac)
  • Motorized or customized wheelchairs, and
  • DME with a purchase price over $5,000
• Growth hormone therapy (GHT)
• Cochlear implants, bone anchored hearing aids, related services and supplies
• Organ transplants
• Medical foods (e.g enteral formula)
• Certain injectable drugs and specialty medications (even when Medicare is your primary insurance);
• The medications listed on selecthealth.org/pharmacy-benefits
• In addition to these services, participating providers must preauthorize other services as specified in SelectHealth, Inc. medical policy.

If you have a question about the preauthorization requirement of a particular item, drug, or service, or for a copy of the prescription drug list, please contact Member or Pharmacy Services at 844-345-FEHB.

First, your physician, your hospital, you, or your representative, must call us at            844-345-FEHB before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• Enrollee’s name and Plan identification number;
• Patient’s name, birth date, identification number and phone number;
• Reason for hospitalization, proposed treatment, or surgery;
• Name and phone number of admitting physician;
• Name of hospital or facility; and
• Number of days requested for hospital stay.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notifications within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us toll-free at 844-208-9012. You may also call OPM’s FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us toll-free at 844-208-9012. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect. 

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you experience an emergency, call 911 or go to the nearest hospital. If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must contact SelectHealth, Inc. once the condition has been stabilized, or as soon as reasonably possible; and, if you are in a non-participating facility, once the emergency condition has been stabilized, you may be asked to transfer to a participating facility in order to continue receiving participating benefits. 

You do not need preauthorization of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for preauthorization of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for preauthorization of additional days for your baby.

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

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. 

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

Services rendered by non-participating providers are not covered on the HDHP Option plan unless urgent and/or emergency related. If you need assistance finding a participating provider, contact SelectHealth, Inc. Member Advocates at 800-515-2220 weekdays, from 7 a.m. to 8 p.m., and Saturdays, from 9 a.m. to 2 p.m. To access the online provider directory, visit www.selecthealth.org/fehb.

If you have a pre-service claim and you do not agree with our decision regarding preauthorization of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call our Appeals Department by writing to P.O. Box 30192 Salt Lake City, UT 84130-0192 or calling toll-free at 844-208-9012.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Preauthorize your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

Cost-sharing is the general term used to refer to your out-of-pocket costs (i.e., deductible, coinsurance and copayments) for the covered care you receive.

A copayment is a fixed amount of money you pay when you receive covered services.

Example: A person on the Standard Option plan seeing a primary care provider would pay a copayment of $15 per office visit and $35 per office visit with a specialist.  

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: A person on the Standard Option Plan would pay a 15% coinsurance for outpatient facility services.

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count towards any deductibles. 

• The calendar year deductible is $250 for Self Only enrollment, $500 for Self Plus One, or $500 for Self and Family enrollment under the Standard Option plan. Under a Self Plus One or Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses reach $500.

  • The calendar year deductible is $500 for Self Only enrollment, $1,000 for Self Plus One, or $1,000 for Self and Family enrollment under the Point-of-Service Product.  Under a Self Plus One or Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses reach $1,000.  

• The calendar year deductible is $1,600 for Self Only enrollment, $3,200 for Self Plus One, or $3,200 for Self and Family enrollment under the High Deductible Health Plan. Under a Self Plus One or Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses reach $3,000. 

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options within this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your prior option to the deductible of your new option.

In addition to the services listed in this brochure, the deductible is waived for the following services:

• Retinopathy screening for diabetes;
• Hemoglobin A1c testing for diabetes;
• Peak flow meter for asthma;
• International Normalized Ratio (INR) testing for liver disease and/or bleeding disorders;
• Low-density Lipoprotein (LDL) testing for heart disease; and
• Certain prescription drugs, such as: Asthma & COPD, Cardiovascular/Antladrenergics, Cardiovascular, Cholesterol, Diabetes - Insulin, Diabetes - Non-Insulin, Mental Health, & Osteoporosis

Any charges from providers and facilities that exceed the SelectHealth, Inc. allowed amount for covered services. 

All deductible, copay and coinsurance amounts are based on the allowed amounts and not on the provider's billed charges. Participating providers and facilities are under contract to accept the SelectHealth, Inc. allowed amount as payment in full for covered services. Non-participating providers and facilities have not agreed to accept the allowed amount for covered services. When this occurs, you are responsible to pay for any charges that exceed the amount that SelectHealth, Inc. pays for covered services. These fees are called excess charges, and they do not apply to your out-of-pocket maximum.

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

After your out-of-pocket expenses, including any applicable deductible, copayments and coinsurance, total $5,000 for Self Only or $10,000 for Self Plus One, or Self and Family enrollment in the HDHP Option; or $5,500 for Self Only or $11,000 for Self Plus One, or Self and Family enrollment in the Standard Option; or $7,500 for Self Only or $15,000 for Self Plus One, or Self and Family enrollment in the Point-of-Service Product in any calendar year, you do not have to pay any more for covered services. 

Example Scenario for a Standard Option plan: Your plan has a $5,500 Self Only maximum out-of-pocket limit and an $11,000 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $5,500 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan. With a Self and Family enrollment out-of-pocket maximum of $11,000, a second family member, or an aggregate of other eligible family members, will continue to accrue additional out-of-pocket qualified medical expenses up to a maximum of $5,500 for the calendar year before their qualified medical expenses will begin to be covered in full.

However the deductible, copayments and coinsurance (if applicable) for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay the deductible, copayments and coinsurance for these services:

• Infertility
• Expenses from utilizing non-participating providers

Be sure to keep accurate records and receipts of your deductibles, copayments and coinsurance to ensure the Plan's calculation of your out-of-pocket maximum is reflected accurately.

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior plan option to the catastrophic protection limit of your new option.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services. 

A surprise bill is an unexpected bill you receive for

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to  www.selecthealth.org/fehb  or contact the health plan at 844-345-FEHB.

• Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

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 provider

$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 Section 3.

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 39. For information on the mental health ABA benefits, see Section 5(e) Mental Health and Substance Use Benefits.

$15 per office visit to a primary care provider

$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

All non-urgent telehealth services - 

Telehealth services are covered in accordance with the SelectHealth, Inc. medical policy when rendered by a participating provider.

Nothing

Tests, such as: 

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

Note: Preauthorization is required for certain diagnostic testing. See Section 3.

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 

Free-standing imaging centers (FSIC) 

Nothing for minor diagnostic tests

Nothing, 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 Section 3. 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/Tdap, 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/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women 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 preventive care benefits for women please visit the Health and Human Services (HHS) website at
  https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to                  https://health.gov/myhealthfinder 

Routine mammogram - covered 

Nothing

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

Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities.

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 30. 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 DTaP/Tdap, 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 may also find a complete list of preventive care services recommended under the USPSTF online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• To build your personalized list of preventive services go to                       
  https://health.gov/myhealthfinder

Nothing

Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities.

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 31. 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 and Postpartum care
• Screening for gestational diabetes
• Delivery
• Screening and counseling for prenatal and postpartum depression

Note: Here are some things to keep in mind:

• You do not need to preauthorize your vaginal or cesarean delivery; see Section 3 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 Section 3.
• 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 their 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.

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

Delivery/$200 per admission (See Section 5(c))

Breastfeeding support, supplies and counseling for each birth

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 on page 44.
• 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 44.

Voluntary sterilization (See Surgical Procedures Section 5(b).

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

$35 per office visit to a specialist for minor surgery

15% of the allowed amount after deductible for major surgery

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 Section 3.

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 Injectable drug benefits found on page 33.

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 Section 3.

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. Infertility is a condition resulting from a disease (an interruption, cessation, or disorder of body functions, systems, or organs) of the individual reproductive tract which prevents the conception of a child through egg-sperm contact after 12 months for an individual under age 35 and 6 months for an individual age 35 and older or the ability to carry a pregnancy to delivery. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

Diagnosis and treatment of infertility specific to:  

Fulguration of ova ducts, hysteroscopy, hysterosalpingogram, certain laboratory tests, diagnostic laparoscopy, and some imaging studies. For a full list of covered medical infertility services, please contact Member Services. 

• Artificial insemination, limited to three cycles annually: 
  • Intravaginal insemination (IVI) 
  • Intracervical insemination (ICI) 
  • Intrauterine insemination (IUI) 
• In vitro fertilization (IVF), limited to three cycles annually 
• Fertility drugs 

Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit. 

Note: Infertility services require preauthorization from your physician. See Section 3. 

Note: Infertility does not apply to the out-of-pocket maximum. 

50% of the allowed amount after deductible

Iatrogenic infertility

• Standard fertility preservation procedures for persons facing the possibility of iatrogenic infertility. 

50% of the allowed amount after deductible 

Not covered:

• Cost of donor sperm
• Cost of donor egg
• Storage fees

• Testing

$15 copay to a primary care provider 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, Inc. Member Services for details.

• Chemotherapy and radiation therapy

Note: Certain radiation therapies and medical oncology drugs require preauthorization. See Section 3.

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

• Growth hormone therapy (GHT)

Note: Growth hormone therapy is covered under the prescription drug benefit and requires preauthorization. See Section 3 and Section 5(f) Prescription Drug Benefits.

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 20.

• 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.

15% of the allowed amount after deductible

Medical food or low-protein modified food products are covered if the following conditions are met:

Hereditary Metabolic Disorders

• Inborn error of amino acid or urea cycle metabolism
• The food product is specifically formulated and used for the treatment of inborn errors of amino acid or urea cycle metabolism
• The food product is used and remains under the direction and supervision of a doctor
• The food product is not a food that is naturally low in protein
• Must be the member’s primary source of nutrition and are primarily given through a form of feeding tube
• Gastrointestinal dysfunction, such as malabsorption, and the product is specifically designed to be used in the management of the condition preventing the ability to maintain adequate weight

Enteral Formula

• Must be the primary source of nutrition
• Must be administered to the patient via tube feeding

Parenteral Formula

• Covered when it provides the total caloric needs by intravenous route when food cannot be consumed orally

Note: Medical foods require preauthorization from your physician. See Section 3.

$15 per office visit to a primary care provider

$35 per office visit to a specialist

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

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, Inc. medical policy

15% of the allowed amount after deductible

Not covered:

• Neutron beam therapy
• Proton beam therapy, except as shown above.
• Over-the-counter formulas used as a replacement for breast milk or normal breastfeeding (e.g. Enfamil®, Similac®, etc.)
• Investigational or experimental formulas
• Formulas not medically necessary

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 20 visits. See Section 3.

Note: Vision therapy services require preauthorization. See Section 3.

Note: Inpatient therapy coverage is limited to 40 days per calendar year for all therapy types combined and requires preauthorization. See Section 3.

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

$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 20 visits. See Section 3.

Note: Inpatient therapy coverage is limited to 40 days per calendar year for all therapy types combined. See Section 3.

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

$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 provider

$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 provider

$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 Section 3.

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 Section 3.

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 Section 3.

Note: Call us at 844-345-FEHB as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare 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:

Incontinence supplies
Batteries are not covered unless when used to power:

• A wheelchair 
• An insulin pump for treatment of diabetes

• Home healthcare 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 Section 3.

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

$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 provider

$35 office visit to a specialist

• Diabetes self management education
• Multicomponent, family centered programs focused on childhood obesity that are part ofintensive behavioral interventions (behavior change counseling for healthy diet and physical activity)
• 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 severe obesity (bariatric surgery), only when rendered at a Metabolic and Bariatric surgery Accreditation and Quality Improvement Program accredited facility. Visit https://selecthealth.org/providers/resources/policies, click general surgery and then click bariatric surgery guidelines for additional information.  
• 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 Section 3 for details on which procedures require preauthorization.

$15 per office visit to a primary care provider 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)
• Gender Affirming Surgery
  • Breast implantation/augmentation
  • Orchiectomy
  • Penectomy
  • Vaginoplasty
  • Clitoroplasty
  • Labiaplasty
  • Subcutaneous mastectomy
  • Hysterectomy
  • Salpingo-oophorectomy
  • Vaginectomy
  • Metoidioplasty
  • Scrotoplasty
  • Urethroplasty
  • Placement of testicular prostheses
  • Phalloplasty
  • Facial feminization surgery

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 affirming surgery requires preauthorization from your physician. For questions regarding specific covered surgical procedures, please contact Member Services at 844-345-FEHB. See Section 3.

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.

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 provider

$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)

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 Section 3.

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 Section 3.

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
  • Hematopoietic stem cell transplant
• 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
  • Hematopoietic stem cell transplant

Note: Organ transplants take place in an inpatient setting and require preauthorization. See Section 3.

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 Section 3.

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 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 Section 3.

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 Section 3.

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 Section 3.

$15 per office visit to a primary care provider 

$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 Section 3.
• 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 Section 3.

15% of the allowed amount after deductible

Hospital level care at home

Note: Hospital level care at home requires preauthorization. See section 3. 

Nothing

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

Outpatient hospital 

• 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 

 Ambulatory surgical center

• 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

$200 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 Section 3.

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 Section 3.

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 Health, 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 Health 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 Health, 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 Health 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 substance use disorders, 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. See Section 3.

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 Healthcare Professionals.

$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, Inc. medical policy when rendered by a participating provider.

Nothing

• 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 require preauthorization. See Section 3.

$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 require preauthorization. See Section 3.

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 provider

$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
• Drugs to treat gender dysphoria
• Fertility drugs (limited, contact Pharmacy Services for more details on covered fertility drugs) 

Note: Selected prescription drugs and supplies require preauthorization from your physician as referenced in Section 3. Contact SelectHealth, Inc. 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, Inc. for more details on covered sexual dysfunction drugs.

Note: For more information on drugs used to treat gender dysphoria contact SelectHealth, Inc.

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 20.

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. 

Note: Infertility services do not apply to the out-of-pocket maximum. 

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. 

Contraceptive drugs and devices as listed in the ACA/HRSA site.

Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below. 

• 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

Note: Generic oral contraceptives, contraceptive rings, contraceptive patches, emergency contraception and select over the counter (OTC) medications are covered 100% in accordance with the Affordable Care Act (ACA). Members utilizing contraceptives that are covered as preventive under the IRS or ACA must still adhere to all SelectHealth medication limitations (i.e., quantity limitations, step therapy, day supply). Members that pay out of pocket for prescriptions may request reimbursement with a Direct Member Reimbursement (DMR). Members are responsible for the difference between the billed amount and the SelectHealth contracted rate in addition to any applicable deductible or copay when using out-of-network pharmacies.

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 healthcare 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 unless specifically indicated elsewhere 
• Prescriptions dispensed in a provider’s office are not covered unless expressly approved by SelectHealth, Inc.

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 42.

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 provider, 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 

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you  may dispute our regular contract benefits decision under the OPM disputed claims process (see Section 8).

Representatives are available during extended hours to answer questions and help resolve concerns. Call Member Services at 844-345-FEHB from 7:00 a.m. to 8:00 p.m. on weekdays, 9:00 a.m. to 2:00 p.m. on Saturdays, or chat with us online via your SelectHealth account.

Whether you need help with behavioral or physical health, Member Advocates can help you find the right care for your needs. They can assist with the following:

• Scheduling an appointment, including care for urgent conditions 
• Finding the closest facility or doctor with the nearest available appointment
• Providing information about a doctor such as age, training certifications, and languages spoken
• Helping you understand and maximize your benefits

Call Member Advocates at 800-515-2220 from 7:00 a.m. to 8:00 p.m. on weekdays, and 9:00 a.m. to 2:00 p.m. on Saturdays. To access the online provider directory, visit               www.selecthealth.org/fehb.

One of the most significant things a person can do to improve overall health is to quit smoking. We offer a free program that can help. Quit for Life^® allows participants to move at their own pace from home. For more information, call 866-784-8454.

Our comprehensive package of online tools and resources allows you to search for participating doctors and facilities, find lower-cost medications, and even create a personalized fitness plan.

Your SelectHealth account, our secure member website, allows you to manage your health information in one location. You can access your account by logging in at www.selecthealth.org/fehb. Once you have logged in, you can access the following tools:

• View your claims by accessing your Explanation of Benefits (EOBs)
• Send a secure message to Member Services
• View your pharmacy claims, and find participating pharmacies
• Improve your health by taking a personal health assessment, tracking your progress, and utilizing other wellness tools
• Access medical records including lab, pathology, and imaging results. You can also email questions to certain Intermountain providers that utilize this program.

Embracing a healthy lifestyle is more convenient when it costs less. As a SelectHealth, Inc. member, you can access discounts on health-related products such as health clubs, massage therapy, medical alarms, and LASIK vision surgery. You can receive these discounts by simply showing your SelectHealth, Inc. ID Card. A complete list is available at www.selecthealth.org/discounts.

SelectHealth^® is a non-profit health plan serving more than one million members in Utah, Idaho, Nevada, and Colorado. For more than 35 years, we’ve been committed to helping our members and everyone in our communities stay healthy. In fact, we share a mission with Intermountain Health® : Helping people live the healthiest lives possible.® Our integration with Intermountain Health helps us ensure high-quality healthcare at the lowest possible cost for our members and the community.

Our prenatal program provides support and resources for expectant mothers. Registered nurses work with moms-to-be and their providers through every trimester and question. There’s no catch and no cost. In addition to expert care and support, each enrollee receives a kit of education materials. The program encourages the following:

• A prenatal exam prior to the 14th week of pregnancy.
• A postpartum exam within 50 days of your delivery date.

For more information, call Healthy Beginnings at 866-442-5052.

The goal of preventive care, such as regular checkups and screenings, is to help you avoid illness and to detect problems when they are most treatable.

Your plan covers preventive care 100 percent—that means no deductible, copay or coinsurance. Examples of preventive services include the following:

• Certain examinations and/or screenings (such as, a mammogram, colon and prostate cancer screenings, etc.)
• Flu and pneumonia vaccinations
• Certain lab-work and tests (such as Pap smears or cholesterol tests)
• Routine immunizations

Checkups may include tests performed by your doctor to manage a known condition, such as treating high blood pressure to prevent a heart attack or a stroke. Services performed to maintain a known condition are not usually considered preventive. Your regular deductible, copay and/or coinsurance will apply to these services.

SelectHealth, Inc. has always been committed to covering preventive services. However, not every preventive service is appropriate every year, and recommended screening guidelines may vary.

We offer online resources that give you access to immunization schedules, tips for women’s health, and information about preventive care exams and tests. You may also complete a personal health assessment and take quizzes about exercise and nutrition.

To encourage you to schedule a preventive care appointment, we have an interactive phone system that delivers education. These calls give you the option to have one of our Member Advocates call you back to help you find a doctor.

Trained registered nurse care managers are available to assist you with various health concerns and can help coordinate services between providers and patients. Our Care Management Programs offer educational materials, newsletters, follow-up phone calls, and additional support. Care Management covers these areas:

• Allergies and rhinitis
• Asthma
• Cancer
• Chronic obstructive pulmonary disease (COPD)
• Depression
• Diabetes
• Heart disease
• High-risk pregnancy
• Migraines

For more information, call Care Management at 800-442-5305.

Participate in the Healthy Living program to improve your health.

Complete a biometric screening and an online health assessment (through your SelectHealth account) and receive an individualized health report. This can help you identify and address health risks. This information will not be shared with your employer. You can access your SelectHealth account by logging in at                      www.selecthealth.org/fehb. 

Healthcare on your schedule - no lines, no waiting room. 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.

The 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

To save time, create a Connect Care account now so it will be ready when you need it. Your information will be stored securely for future visits.

A phone call could save you money - and an ER visit. Instead of relying on the Internet for self-diagnosis, our members can pick up the phone and talk to a registered nurse for free at any time (24/7) through Intermountain Health Answers. Using nationally standardized protocols, these nurses can help you make sense of your symptoms and determine how and where to get the best care.

To reach Health Answers, call 844-501-6600.

If you are traveling outside of the country and need urgent or emergency care, visit the nearest doctor or hospital. Notify us of your circumstances as soon as possible. You may be required to pay for treatment at the time of service and then submit an itemized statement or claim to SelectHealth, Inc. If the service is covered, you will be reimbursed the allowed amount minus your Copayment/Coinsurance and/or Deductible. All services obtained outside of the United States unless routine, urgent or emergency condition require preauthorization. See Section 3. Our Care Management team may become involved to help with any out-of-country health issues or claims that are particularly complicated. Participating benefits apply to emergency room services regardless of whether they are received at a participating facility or nonparticipating facility. Participating benefits apply to Services received for Urgent Conditions rendered by a non-participating provider or facility when you are outside of the service area, or within the service area when you are more than 40 miles away from any participating provider or facility.

Finding a balance of fitness and nutrition that works for your body is important for a lasting weight management program. The Intermountain Weigh to Health program is for SelectHealth members (ages 18+) who want to lose weight, improve their health, and feel better every day. This program works because:

• It's personal. You choose the classes that will help you learn the skills and knowledge you need.
• It's professional. The program is led by registered dietitians with training and experience in weight management. Guest lectures are taught by professionals with other areas of expertise.
• It's proven. The program is based on the latest evidence about what works for weight loss and for making changes that last a lifetime.

SelectHealth, Inc. will cover the cost of the program once per calendar year for eligible members who complete all course requirements.

Contact SelectHealth, Inc. at 844-345-FEHB to verify your coverage.

If you've got your phone, we've got you covered. With the SelectHealth^® mobile app, you have access to your health plan whenever - and wherever - you need it.

Access your insurance plan on the go. With our secure app, you can:

• View and download images of your ID card
• Search for doctors and hospitals
• View your benefits and claims, including year-to-date totals
• Look up pharmacies and medications

Find us on Google Play^® and the Apple^® App Store.^SM

Participate in the FEHB wellness incentive program to improve your health and earn an incentive. Eligible members must be age 18 or older and enrolled on a SelectHealth, Inc. FEHB plan option. Log in to the SelectHealth account at www.selecthealth.org/fehb to access the health risk assessment.

Receive up to a combined total of either $250 per year or $500 per year for completion of qualified wellness events. Incentive dollars earned will be transferred into an HIA set up with our third-party administrator, HealthEquity. Contact Member Services at 844-345-FEHB or visit www.selecthealth.org/fehb for more information.

The plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), routine prenatal and well-child care, child and adult immunizations, tobacco cessation programs, obesity weight loss programs, disease management and wellness programs. These services are covered at 100% if you use a network provider and the services are described in Section 5 Preventive Care. You do not have to meet the deductible before using these services.

After you have paid the plan's deductible, we pay benefits under traditional medical coverage described in Section 5.

Covered services include:

• Medical services and supplies provided by physicians and other healthcare professionals
• Surgical and anesthesia services provided by physicians and other healthcare professionals
• Hospital services, other facility or ambulance services
• Emergency services/accidents
• Mental health and substance use disorder benefits
• Prescription drug benefits
• Dental benefits

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see page 74 for more details). 

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else's tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan.

In 2023, for each month you are eligible for premium pass through, we will contribute $75 per month or $900 annually for Self Only enrollment or $150 per month or $1,800 annually for Self Plus One enrollment or $150 per month or $1,800 annually for a Self and Family enrollment. In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $3,650 for an individual and $7,300 for a family. See maximum contribution information found in HDHP Option Section 5. Savings - HSAs and HRAs on page 74.

You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don't deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

https://www.opm.gov/healthcare-insurance/healthcare/health-savings-accounts/frequently-asked-questions/

HSA features include:

• Your HSA is administered by HealthEquity
  • For questions regarding your HSA administered by HealthEquity, call 866-346-5800 or visit www.healthequity.com
• Your contributions to the HSA are tax deductible
• You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.)
• Your HSA earns tax-free interest
• You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS publication 502 for a complete list of eligible expenses)
• Your unused HSA funds and interest accumulate from year to year
• It is portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire
• When you need it, funds up to the actual HSA balance are available

Important consideration if you want to participate in a Healthcare Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA) and start or become covered by a HCFSA healthcare flexible spending account (such as FSAFEDS offers - see Section 11), this HDHP cannot continue to contribute to your HSA. Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your coverage in an HCFSA, we will establish an HRA for you.

If you are not eligible for an HSA, for example, you are enrolled in Medicare or have another health plan, we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA.

In 2023, we will give you an HRA credit of $900 per year for a Self Only enrollment or $1,800 per year for a Self Plus One enrollment or $1,800 per year for a Self and Family enrollment. You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that do not count toward the deductible.

HRA features include:

• For our HDHP option, the HRA is administered by HealthEquity
  • If you have questions regarding your HRA administered by HealthEquity, call 866-346-5800 or visit www.healthequity.com
• Entire HRA credit (prorated from your effective date to the end of the plan year) is available at the beginning of your enrollment period
• Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP
• Unused credits carryover from year to year
• HRA credit does not earn interest
• HRA credit is forfeited if you leave Federal employment or switch health insurance plans
• An HRA does not affect your ability to participate in an FSAFEDS Healthcare Flexible Spending Account (HCFSA); however, you must meet FSAFEDS eligibility requirements

When you use network providers, your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $5,000 per person or $10,000 per Self Plus One enrollment or, $10,000 Self and Family enrollment. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan's allowable amount or benefit maximum). Refer to Section 4 Your catastrophic protection out-of-pocket maximum and HDHP Option Section 5 Traditional medical coverage subject to the deductible for more details.

Access education resources and tools are available at www.selecthealth.org/fehb and www.healthequity.com.

Participate in the FEHB wellness incentive program to improve your health and earn an incentive. Eligible members must be age 18 or older and enrolled on a SelectHealth, Inc. FEHB plan option. Log in to the SelectHealth Member Portal at
www.selecthealth.org/fehb to access the health risk assessment.

Receive up to a combined total of either $250 per person per year or $500 per family per year for completion of qualified wellness events. Incentive dollars earned will be transferred into the subscriber’s HSA or HRA set up with our third-party administrator, HealthEquity. Contact Member Services at 844-345-FEHB or visit www.selecthealth.org/fehb for more information.

Health Savings Account (HSA)

Health Reimbursement Arrangement (HRA)

Provided when you are ineligible for an HSA

The Plan will establish an HSA for you with HealthEquity. HealthEquity is the non-bank custodian and preferred HSA administrator for this Plan. HealthEquity has a relationship with Charles Schwab Bank to manage the investment options for members with an HSA. Members can contact HealthEquity directly for assistance at 866-346-5800.

SelectHealth, Inc. is the HRA fiduciary for this Plan. HealthEquity is the HRA administrator for this Plan. Members can contact HealthEquity directly for assistance at 866-346-5800.

Set-up fee is paid by the Plan. 

No administrative fee is charged by the Plan.

A HealthEquity set-up fee of $20.00 is charged when you fail to notify SelectHealth, Inc. within 30 days of enrollment that an HRA is needed instead of an HSA.

You must:

• Enroll in this HDHP
• Not be enrolled in another health plan that is not eligible to be paired with an HSA (does not apply to specific injury, accident, disability, dental, vision or long-term care coverage)
• Not be enrolled in Medicare Part A or
  Part B
• Not be claimed as a dependent on someone else's tax return
• Not have received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits in the last three months

You must enroll in this HDHP.

Eligibility is determined on the first day of the month following your effective day of enrollment and will be prorated for length of enrollment.

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month.

Premium pass through contributions are based on the effective date of your enrollment in the HDHP. If your eligibility date is after the first of the month, your HSA account will be established and funded the beginning of the following month.

A debit card will be issued to you at the time of enrollment and can be used to pay for eligible medical expenses.

Eligibility for the annual credit will be determined on the first day of the month and will be prorated for length of enrollment. The entire amount of your HRA will be available to you at the beginning of your enrollment period.

For 2023, a monthly premium pass through of $75.00 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $900 (prorated for mid-year enrollment).

For 2023, a monthly premium pass through of $150.00 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $1,800 (prorated for mid-year enrollment).

For 2023, a monthly premium pass through of $150.00 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $1,800 (prorated for mid-year enrollment).

The maximum that can be contributed to your HSA is an annual combination of HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $3,650 for an individual and $7,300 for a family in 2023.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum allowable contribution.

You are eligible to contribute up to the IRS limit for partial year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12 month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA. If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Additional contribution discussed later in HDHP Option Section 5. Savings - HSAs and HRAs found on page 77.

The full HRA credit will be available, subject to proration, at the beginning of your enrollment period. The HRA does not earn interest.

You may make an annual maximum contribution of up to $2,750.

You cannot contribute to the HRA.

You may make an annual maximum contribution of up to $5,500.

You cannot contribute to the HRA.

You may make an annual maximum contribution of up to $5,500.

You cannot contribute to the HRA.

You can access your HSA by the following methods:

• Debit card
• Withdrawal form
• Checks
• Electronic funds transfer

For qualified medical expenses under your HDHP, you will be automatically reimbursed when claims are submitted through the HDHP. For expenses not covered by the HDHP, such as dental services, a reimbursement form will be sent to you upon your request. A debit card issued to you at the time of enrollment can be used to pay for eligible medical expenses (see IRS Publication 502). Claim payments made by HealthEquity on behalf of an HDHP enrollee may have to be validated by the enrollee, prior to HRA reimbursement.

You can pay the out-of-pocket expenses for yourself, your spouse or your dependents (even if they are not covered by the HDHP) from the funds available in your HSA.

Your HSA is established the first of the month following the effective date of your enrollment in this HDHP. For most Federal enrollees (those not paid on a monthly basis), the HDHP becomes effective the first pay period in January 2023. If the HDHP is effective on a date other than the first of the month, the earliest date medical expenses will be allowable is the first of the next month. If you were covered under an HDHP in 2022 and remain enrolled in an HDHP, your medical expenses incurred January 1, 2023 or later, will be allowable.

See IRS Publication 502 for a list of eligible medical expenses.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan. You must submit these expenses with a claim form for reimbursement (available within your HealthEquity web portal).

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publication 502 for a list of eligible medical expenses. Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable. Most other types of insurance premiums are not reimbursable.

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty, however they will be subject to ordinary income tax.

Not applicable - distributions will not be made for anything other than non-reimbursed qualified medical expenses.

Funds are not available for withdrawal until all the following steps are completed:

• Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change).
• The HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish.

Funds are available at the beginning of your enrollment period.

• Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change); and
• The HDHP receives record of your enrollment and you notify SelectHealth, Inc. of the need to establish an HRA on your behalf.
• A HealthEquity set-up fee of $20.00 is charged when you fail to notify SelectHealth, Inc. within 30 days of enrollment that an HRA is needed instead of an HSA.

FEHB enrollee

HDHP

You can take this account with you when you change plans, separate or retire.

If you do not enroll in another HDHP, you can no longer contribute to your HSA. See Eligibility found in HDHP Option Section 5. Savings - HSAs and HRAs on page 74.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited.

Yes, accumulates without a maximum cap.

Yes, accumulates without a maximum cap.

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS. You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit. If you contribute, you can claim the total amount you contributed for the year as a tax deduction when you file your income taxes. Your own HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction). You receive tax advantages in any case. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15 of the following year to make HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season and your effective date is after January 1st or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

If you are age 55 or older, the IRS permits you to make additional contributions to your HSA. The allowable contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the IRS website at www.irs.gov or request a copy of IRS Publication 969 by calling 1-800-829-3676.

If you have not named a beneficiary and you are married, your HSA becomes your spouse's; otherwise, your HSA becomes part of your taxable estate.

You can pay for "qualified medical expenses," as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 800-829-3676, or visit the IRS website at www.irs.gov and click on "Forms and Publications." Note: Although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances.

You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.

You will receive periodic notification(s) that shows the "premium pass through", withdrawals, and interest earned on your account. Additionally, you will receive notification when you withdraw money from your HSA.

You can request reimbursement up to the account balance of your HSA.

If you do not qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you.

If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you. You must tell us if you are ineligible for an HSA or become ineligible to contribute to an HSA.

A HealthEquity set-up fee of $20.00 is charged when you fail to notify SelectHealth, Inc. within 30 days of enrollment that an HRA is needed instead of an HSA.

Please review the chart at the beginning of HDHP Option Section 5. Savings - HSAs and HRAs found on page 74 which details the differences between an HRA and an HSA. The major differences are:

• You cannot make contribution to an HRA
• Funds are forfeited if you leave the HDHP
• An HRA does not earn interest
• HRAs can only pay for qualified medical expense, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP. FEHB law does not permit qualified medical expenses to include services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.

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/Tdap, 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/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women 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 preventive care benefits for women please visit the Health and Human Services (HHS) website at
  https://www.healthcare.gov/preventive-care-women/

Nothing

Routine mammogram - covered 

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

Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related
comorbidities.

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 https://www.uspreventiveservicestaskforce.org

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

To build your personalized list of preventive services go to 
https://health.gov/myhealthfinder

Nothing

Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity
related comorbidities.

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 $1,600 per person, $3,200 per Self Plus One enrollment or $3,200 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 provider

$30 per office visit to a specialist

• In an urgent care center

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

Note: KidsCare clinics are owned by Intermountain Health 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 Section 3.

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 89. 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 provider

$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

All non-urgent telehealth services –

Telehealth services are covered in accordance with the SelectHealth, Inc. medical policy when rendered by a participating provider.

Nothing

Tests, such as:

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

Note: Preauthorization is required for certain diagnostic testing. See Section 3.

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 

Free-standing imaging centers (FSIC) 

Nothing, after deductible 

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 Section 3. 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 and Postpartum care
• Delivery
• Screening and counseling for prenatal and postpartum depression

Note: Here are some things to keep in mind:

• You do not need to preauthorize your vaginal or cesarean delivery; see Section 3 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 Section 3.
• 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 their 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.

A single office visit copay of $10 when pregnancy is confirmed; nothing for subsequent prenatal or postpartum care.

Delivery/$100 per admission (See Section 5(c))

Screening for gestational diabetes 

Nothing

Breastfeeding support, supplies and counseling for each birth

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. 
• 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).

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 Section 3.

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 Section 3.

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. Infertility is a condition resulting from a disease (an interruption, cessation, or disorder of body functions, systems, or organs) of the individual reproductive tract which prevents the conception of a child through egg-sperm contact after 12 months for an individual under age 35 and 6 months for an individual age 35 and older or the ability to carry a pregnancy to delivery. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

Diagnosis and treatment of infertility specific to: 

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 Member Services. 

• Artificial insemination, limited to three cycles annually: 
  • Intravaginal insemination (IVI) 
  • Intracervical insemination (ICI) 
  • Intrauterine insemination (IUI) 
• In vitro fertilization (IVF), limited to three cycles annually 
• Fertility drugs 

Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit. 

Note: Infertility services require preauthorization from your physician. See Section 3. 

Note: Infertility does not apply to the out-of-pocket maximum. 

50% of allowed amount

Iatrogenic infertility

• Standard fertility preservation procedures for persons facing the possibility of iatrogenic infertility 

50% of the allowed amount 

Not covered:

• Cost of donor sperm
• Cost of donor egg
• Storage fees 

All charges

• Testing

$10 per office visit to a primary care provider 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, Inc. Member Services for details.

All charges

• Chemotherapy and radiation therapy

Note: Certain radiation therapies and medical oncology drugs require preauthorization. See Section 3.

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

• Growth hormone therapy (GHT)

Note: Growth hormone therapy is covered under the prescription drug benefit and requires preauthorization. See Section 3 and Section 5(f) Prescription Drug Benefits.

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.

• 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.

$150 per day

Medical food or low-protein modified food products are covered if the following conditions are met:

Hereditary Metabolic Disorders

• Inborn error of amino acid or urea cycle metabolism
• The food product is specifically formulated and used for the treatment of inborn errors of amino acid or urea cycle metabolism
• The food product is used and remains under the direction and supervision of a doctor
• The food product is not a food that is naturally low in protein
• Must be the member’s primary source of nutrition and are primarily given through a form of feeding tube
• Gastrointestinal dysfunction, such as malabsorption, and the product is specifically designed to be used in the management of the condition preventing the ability to maintain adequate weight

Enteral Formula

• Must be the primary source of nutrition
• Must be administered to the patient via tube feeding

Parenteral Formula

• Covered when it provides the total caloric needs by intravenous route when food cannot be consumed orally

Note: Medical foods require preauthorization from your physician. See Section 3.

$10 per office visit to a primary care provider

$30 per office visit to a specialist

$150 per day for outpatient facility services

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

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, Inc. medical policy

$150 per day

Not covered:

•  Neutron beam therapy
•  Proton beam therapy, except as shown above
•  Over-the-counter formulas used as a replacement for breast milk or normal breastfeeding (e.g. Enfamil®, Similac®, etc.)
•  Investigational or experimental formulas
•  Formulas not medically necessary

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 20 visits. See Section 3.

Note: Vision therapy services require preauthorization. See Section 3.

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.

$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 20 visits. See Section 3.

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.

$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 provider

$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 provider

$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 provider

$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 Section 3.

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 Section 3.

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 Section 3.

Note: Call us at 844-345-FEHB as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare 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:
Incontinences supplies
Batteries are not covered unless when used to power:

• A wheelchair
• An insulin pump for treatment of diabetes

All charges

• Home healthcare 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 Section 3.

$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

$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
• Multicomponent, family centered programs focused on childhood obesity that are part of intensive
  behavioral interventions (behavior change counseling for healthy diet and physical activity)
• 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 severe obesity (bariatric surgery), only when rendered at a Metabolic and Bariatric surgery Accreditation and Quality Improvement Program accredited facility. Visit https://selecthealth.org/providers/resources/policies, click general surgery and then click bariatric surgery guidelines for additional information. 
• 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 Section 3 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)
• Gender Affirming Surgery
  • Breast implantation/augmentation
  • Orchiectomy
  • Penectomy
  • Vaginoplasty
  • Clitoroplasty
  • Labiaplasty
  • Subcutaneous mastectomy
  • Hysterectomy
  • Salpingo-oophorectomy
  • Vaginectomy
  • Metoidioplasty
  • Scrotoplasty
  • Urethroplasty
  • Placement of testicular prostheses
  • Phalloplasty
  • Facial feminization surgery

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 Affirming surgery requires preauthorization from your physician. See Section 3. 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.

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 provider 

$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 Section 3.

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 Section 3.

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
• Hematapoietic stem cell transplant
• 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
• Hematopoietic stem cell transplant

Note: Organ transplants take place in an inpatient setting and require preauthorization. See Section 3.

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 Section 3.

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 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 Section 3.

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 Section 3.

Nothing

Professional services provided in:

• Office

Note: Certain pain management services require preauthorization from your physician. See Section 3.

$10 per office visit to a primary care provider

$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 Section 3.
• 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 Section 3.

$150 per day up to $750 per admission

Hospital level care at home

Note: Preauthorization is required for Hospital level care at home.                See section 3

Nothing 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

All charges

Outpatient hospital

• 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

Ambulatory surgical center 

• 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

Nothing 

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 Section 3.

$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 Section 3.

$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 Health, 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 Health 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 Health, 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 Health 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 substance use disorders 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. See Section 3.

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 HealthCare Professionals.

$10 per office visit

Nothing for inpatient or outpatient professional services

$150 per day for outpatient facility services

$150 per day up to $750 per admission for inpatient facility 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 require preauthorization. See Section 3.

$10 per office visit

Nothing for minor diagnostic tests

$150 copay for major diagnostic tests

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 require preauthorization. See Section 3.

$150 copay per day up to $750 per 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

$10 per office visit

$150 copay per day for outpatient facility services

Methadone maintenance, associated clinics or services

$10 per office visit to a primary care provider

$30 per office visit to a specialist

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
• Drugs to treat gender dysphoria
• Fertility drugs (limited, contact Pharmacy Services for more details on covered fertility drugs) 

Note: Selected prescription drugs and supplies require preauthorization from your physician as referenced in Section 3 found on page 20. Contact SelectHealth, Inc. 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, Inc. for more details on covered sexual dysfunction drugs.

Note: For more information on drugs used to treat gender dysphoria contact SelectHealth, Inc.

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 found in Section 3, located on page 20.

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.

Note: Infertility services do not apply to the out-of-pocket maximum. 

Prescription Medications
Tier 1  $7
Tier 2  $25
Tier 3  $50
Tier 4  30% of the allowed amount

Mail Order
Maintenance Medications - 90 day supply
Tier 1  $7
Tier 2  $50
Tier 3  $150

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 healthcare 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, Inc.