Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2025 - 12/31/2025

Coverage for: Single/Family | Plan Type: TIER

BOWEN COLLINS & ASSOCIATES
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost
for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit [Link] or call 800-538-5038. For
general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the
Glossary. You can view the Glossary at [Link]/sbc or call 800-538-5038 to request a copy.
Important Questions Answers Why this Matters:
Generally, you must pay all the costs from providers up to the deductible amount before this
$5,000 person/$10,000 family in-network
What is the overall plan begins to pay. If you have other family members on the plan, each family member must
and $7,000 person/$14,000 family out-of-
deductible? meet their own individual deductible until the total amount of deductible expenses paid by all
network per calendar year.
family members meets the overall family deductible.
Yes, for in-network providers: preventive This plan covers some items and services even if you haven’t yet met the deductible amount. But
Are there services
care, office visits, prescription drugs, and a copayment or coinsurance may apply. For example, this plan covers certain preventive
covered before you meet
chiropractic services are covered before you services without cost sharing and before you meet your deductible. See a list of covered
your deductible?
meet your deductible. preventive services at [Link]
Are there other
Yes. $100 per person for prescription drugs. You must pay all of the costs for these services up to the specific deductible amount before this
deductibles for specific
There are no other specific deductibles. plan begins to pay for these services.
services?
$6,000 person/$12,000 family in-network The out-of-pocket limit is the most you could pay in a year for covered services. If you have
What is the out-of-pocket
and $12,000 person/$24,000 family out-of- other family members in this plan, they have to meet their own out-of-pocket limits until the
limit for this plan?
network. overall family out-of-pocket limit has been met.
Premiums, balance-billed charges,
What is not included in healthcare this plan doesn't cover, and
Even though you pay these expenses, they don't count toward the out-of-pocket limit.
the out–of–pocket limit? penalties for failure to obtain
preauthorization for services.

This plan uses a provider network. You will pay less if you use a provider in the plan’s
Yes. To find an in-network provider visit network. You will pay the most if you use an out-of-network provider, and you might receive a
Will you pay less if you
[Link]/findadoctor or call bill from a provider for the difference between the provider’s charge and what your plan pays
use a network provider?
Member Services at 800-538-5038. (balance billing). Be aware your network provider might use an out-of-network provider for
some services (such as lab work). Check with your provider before you get services.

Do you need a referral to

No. You can see the specialist you choose without a referral.
see a specialist?

* For more information about limitations and exceptions, see the plan or policy document at [Link]/materials. 1 of 8
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common Tier 1 Tier 2 Out-of-Network Provider Limitations, Exceptions, & Other
Services You May Need
Medical Event Network Provider Network Provider (You will pay the most) Important Information
(You will pay the least)

A different benefit may apply for major

Primary care visit to treat
$20/visit $20/visit 40% co-insurance office surgery. Deductible does not apply
an injury or illness (PCP)
to in-network services.
Certain limitations apply to allergy testing,
If you visit a health
treatment and serum. A different benefit
care provider’s office
Specialist visit (SCP) $40/visit $40/visit 40% co-insurance may apply for major office surgery.
or clinic
Deductible does not apply to in-network
services.

Preventive care / Frequency limitations apply. Deductible

No charge No charge Not covered
screening / immunization does not apply to in-network services.
Diagnostic test (x-ray, Deductible does not apply to in-network
No charge No charge 40% co-insurance
blood work) services.
If you have a test
Imaging (CT/PET scans,
No charge No charge 40% co-insurance ----------None----------
MRIs)
Standard Tier 1 (generic
$15/prescription $15/prescription $15/prescription
drugs)
Standard Tier 2 (preferred
$30/prescription $30/prescription $30/prescription
brand drugs)
If you need drugs to Certain limitations apply. Benefits may be
Standard Tier 3 (non-
treat your illness or $50/prescription $50/prescription $50/prescription denied or reduced by 50% for failure to
preferred brand drugs)
condition obtain preauthorization for certain
Maintenance Tier 1
More information about $15/prescription $15/prescription $15/prescription services. Pharmacy deductible waived for
(generic drugs)
prescription drug tier 1.
Maintenance Tier 2
coverage is available at $60/prescription $60/prescription $60/prescription
(preferred brand drugs)
[Link]/prescr
Maintenance Tier 3 (non-
iptions/[Link]?st $150/prescription $150/prescription $150/prescription
preferred brand drugs)
=ut&plan=select
No charge for medical, No charge for medical, 40% co-insurance for Benefits may be denied or reduced by 50%
Specialty drugs $100/prescription for $100/prescription for medical, $100/prescription for failure to obtain preauthorization for
pharmacy pharmacy for pharmacy certain services.
* For more information about limitations and exceptions, see the plan or policy document at [Link]/materials. 2 of 8
 What You Will Pay
Common Tier 1 Tier 2 Out-of-Network Provider Limitations, Exceptions, & Other
Services You May Need
Medical Event Network Provider Network Provider (You will pay the most) Important Information
(You will pay the least)

Facility fee (e.g.,

If you have No charge No charge 40% co-insurance ----------None----------
ambulatory surgery center)
outpatient surgery
Physician/surgeon fees No charge No charge 40% co-insurance ----------None----------
Emergency room Emergency room services apply to in-
$150/visit $150/visit $150/visit
services network benefits.
Emergencies only. Emergency medical
Emergency medical
If you need immediate No charge No charge No charge transportation applies to in-network
transportation
medical attention benefits.
Applies to urgent care facilities only.
Urgent care $50/visit $50/visit 40% co-insurance Deductible does not apply to in-network
services.
Facility fee (e.g., hospital Benefits may be denied or reduced by 50%
If you have a hospital No charge No charge 40% co-insurance
room) for failure to obtain preauthorization for
stay
Physician/surgeon fee No charge No charge 40% co-insurance certain services.
$20 for office visits, $20 for office visits, 40% co-insurance for Benefits may be denied or reduced by 50%
If you need mental Outpatient services no charge for no charge for office visits, 40% co- for failure to obtain preauthorization for
health, behavioral outpatient outpatient insurance for outpatient certain services. Additional limitations and
health, or substance exclusions apply. Deductible does not
abuse services Inpatient services No charge No charge 40% co-insurance apply to in-network office visits and
outpatient services.
A different benefit may apply for major
Office visits $20/visit $20/visit 40% co-insurance office surgery. Deductible does not apply
to in-network services.
If you are pregnant Childbirth/delivery Benefits may be denied or reduced by 50%
No charge No charge 40% co-insurance for failure to obtain preauthorization for
professional services
certain services. Depending on the type of
Childbirth/delivery facility services, a copayment, coinsurance, or
No charge No charge 40% co-insurance
services deductible may apply.

* For more information about limitations and exceptions, see the plan or policy document at [Link]/materials. 3 of 8
 What You Will Pay
Common Tier 1 Tier 2 Out-of-Network Provider Limitations, Exceptions, & Other
Services You May Need
Medical Event Network Provider Network Provider (You will pay the most) Important Information
(You will pay the least)
Benefits may be denied or reduced by 50%
Home health care No charge No charge 40% co-insurance for failure to obtain preauthorization for
certain services.
Up to 40 days per calendar year for
inpatient physical, speech, and
$40/visit for outpatient, $40/visit for outpatient, occupational therapies combined. Benefits
Rehabilitation services 40% co-insurance
No charge for inpatient No charge for inpatient may be denied or reduced by 50% for
failure to obtain preauthorization for
certain services.
If you need help Benefits may be denied or reduced by 50%
recovering or have Habilitation services $40/visit $40/visit 40% co-insurance for failure to obtain preauthorization for
other special health certain services.
needs Up to 60 days per calendar year. Benefits
may be denied or reduced by 50% for
Skilled nursing care No charge No charge 40% co-insurance
failure to obtain preauthorization for
certain services.
Benefits may be denied or reduced by 50%
Durable medical
No charge No charge 40% co-insurance for failure to obtain preauthorization for
equipment (DME)
certain services.
Benefits may be denied or reduced by 50%
Hospice service No charge No charge 40% co-insurance for failure to obtain preauthorization for
certain services.
Deductible does not apply to in-network
Children's eye exam $40/visit $40/visit 40% co-insurance
If your child needs services.
dental or eye care Children's glasses Not covered Not covered Not covered Glasses are not covered.
Children's dental check-up Not covered Not covered Not covered Dental check-ups are not covered.

* For more information about limitations and exceptions, see the plan or policy document at [Link]/materials. 4 of 8
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Abortions/termination of pregnancy except in limited • Hearing aids
circumstances • Immunizations for Anthrax, BCG, Cholera, Plague,
• Acupuncture Typhoid and Yellow Fever
• Administrative services/charges • Infertility treatment
• Cosmetic surgery and reconstructive and corrective • Long-term care
services, except in limited circumstances • Orthotic and other corrective appliances for the foot
• Dental care (adult/child), except in limited • Services for which a third-party is or may be
circumstances responsible
• Dental check-up • Services that are not medically necessary
• Experimental and/or investigational services • Temporomandibular Joint (TMJ) services greater than
• Glasses $2,000 lifetime

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Bariatric surgery, preauthorization required with • Non-emergency care when traveling outside the U.S. • Routine eye care (adult)
limitations • Private Duty Nursing, preauthorization required with • Routine foot care
• Chiropractic care limitations • Weight loss programs as part of a program approved by
SelectHealth

* For more information about limitations and exceptions, see the plan or policy document at [Link]/materials. 5 of 8
Your Rights to Continue Coverage:
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits
Security Administration at 1-866-444-EBSA (3272) or [Link]/ebsa/healthreform; or Department of Health and Human Services, Center for Consumer Information and
Insurance Oversight, at 1-877-267-2323 x61565 or [Link]; or contact the Plan. Other coverage options may be available to you too, including buying individual
insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit [Link] or call 1-800-318-2596.

Your Grievance and Appeals Rights:

There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about
your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a
grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Department of Labor's Employee Benefits Security
Administration at 866-444-EBSA (3272) or [Link]/ebsa/healthreform; or If your coverage is fully-insured, you may also contact the Utah Insurance Department, Office of
Consumer Assistance, Suite 3110, State Office Building, Salt Lake City, Utah 84114.

To contact Select Health Member Services, please call 800-538-5038 weekdays, TTY users should call 711, or visit us at [Link].

Does this plan provide Minimum Essential Coverage? Yes

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,
TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

* For more information about limitations and exceptions, see the plan or policy document at [Link]/materials. 6 of 8
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on
the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and
coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please
note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a hospital (a year of routine in-network care of a well-controlled (in-network emergency room visit and follow up care)
delivery) condition)

◼ The plan’s overall deductible $5,000 ◼ The plan’s overall deductible $5,000 ◼ The plan’s overall deductible $5,000
◼ Specialist $40 ◼ Specialist $40 ◼ Specialist $40
◼ Hospital (facility) overed 100%
Covered ◼ Hospital (facility) Covered 100% ◼ Hospital (facility) Covered 100%
◼ Other overed 100%
Covered ◼ Other Covered 100% ◼ Other Covered 100%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $5,000 Deductibles $800 Deductibles $2,500
Copayments $10 Copayments $600 Copayments $100
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $5,070 The total Joe would pay is $1,420 The total Mia would pay is $2,600

The plan would be responsible for the other costs of these EXAMPLE covered services.
G1022022 1001 L40M0882
8/23/2024

* For more information about limitations and exceptions, see the plan or policy document at [Link]/materials. 7 of 8
Non-Discrimination Notice
Select Health obeys Federal civil rights laws. We do not treat you differently because of your race, color, ethnic background or where you come from, age, disability, sex, religion,
creed, language, social class, sexual orientation, gender identity or expression, and/or veteran status.
We provide free aid and services to people with disabilities to help them communicate effectively with us, such as qualified sign language interpreters and written information in
other formats (large print, audio, accessible electronic formats, other formats). We also provide free language services to people whose primary language is not English, such as
qualified interpreters and member materials written in other languages.
If you need these services, please call Select Health Member Services at 800-538-5038 or Select Health Advantage Member Service at 855-442-9900. Any member or other
person who believes he/she may have been subject to discrimination may file a complaint or grievance by calling the SelectHealth 504/Civil Rights Coordinator at 844-208-9012 or
the Compliance Hotline at 800-442-4845 (TTY Users: 711). You may also call the Office for Civil Rights at 1-800-368-1019 (TTY Users: 800-537-7697).

Language Access Services

Spanish Tagalog Amharic
ATENCIÓN: Si habla español, tiene a su disposición PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari ማሳሰቢያ፡ አማርኛ የሚናገሩ ከሆነ፣ የቋንቋ ድጋፍ
servicios gratuitos de asistencia lingüística. Llame a kang gumamit ng mga serbisyo ng tulong sa wika አገልግሎቶች ያለክፍያ ለእርስዎ ይገኛሉ። Select
Select Health. nang walang bayad. Tumawag sa Select Health.
Health ን ያናግሩ።
Chinese Serb-Croatian
German
注意：如果您使用繁體中文，您可以免費獲得 ПАЖЊА: Ако говорите Српски, бесплатне услуге
ACHTUNG: Wenn Sie Deutsch sprechen, stehen
語言援助服務。請致電 Select Health Ihnen kostenlos sprachliche Hilfsdienstleistungen zur пмоћи за језик, биће вам доступне. Контактирајте
Verfügung. Rufnummer: Select Health. Select Health.
Vietnamese
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ Russian Arabic
trợ ngôn ngữ miễn phí dành cho bạn. Gọi số ВНИМАНИЕ: Если вы говорите на русском языке, ‫هيبنت‬: ‫ىبرع ثدحتت تنك اذإ‬، ‫تامدخ كل رفوتتسف‬
то вам доступны бесплатные услуги переводчика. ‫ ةدعاسم‬‫ا ًناجم ةيوغل‬. ‫ ب لصتا‬Select Health.
Select Health.
Позвоните Select Health.
Korean Persian
통지: 한국어를 사용하시는 경우, 언어 지원 French ‫هجوت‬: ‫دينکيم تبحص ينک دراو ار نابز هب رگا‬، ‫تامدخ‬
서비스를 무료로 이용하실 수 있습니다. ATTENTION: si vous parlez français, des services ‫ينابز کمک‬، ‫تسامش رايتخا رد ناگيار تروصب‬. ‫اب‬
d’aide linguistique vous sont proposés gratuitement. Select Health .‫ديريگب سامت‬.
Select Health. 번호로 전화해 주십시오.
Contactez Select Health.
Thai
Nepali Japanese หมายเหตุ: หากคุณพูด ใส่ภาษา, การบริการภาษา
โดยไม่มีค่าใช ้จ่าย มีพร้อมบริการให้กับคุณ ติดต่อ
यान दिनुहोस्: तपाले नेपाली बोल््ननुनुहु न््छ भने 注意事項：日本語を話される場合、無料の
Select Health
तपाको नन तत भाषा सहायता सेवाह नन शुक 言語支援をご利用いただけます。Select
पमा उपलध छ। Select Health मा फोन गर््ननुनुहोस्। Health. まで、お電話にてご連絡ください。
Select Health: 1-800-538-5038

* For more information about limitations and exceptions, see the plan or policy document at [Link]/materials. 8 of 8
BOWEN COLLINS & ASSOCIATES G1022022 1001 L40M0882 01/01/2025
MEMBER PAYMENT SUMMARY
TIER 1 TIER 2 OUT-OF-
VALUE MED NETWORK
When using In-Network Providers, you are When using In-Network Providers, you are When using Out-of-Network Providers,
VALUE AND MED NETWORKS responsible to pay the amounts in this responsible to pay the amounts in this you are responsible to pay the amounts in
column. These providers might not be column. this column.
available in all areas.
5,6
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET IN-NETWORK IN-NETWORK OUT-OF-NETWORK
Self Only Coverage, 1 person enrolled - per calendar Year
Deductible $5,000 $7,000
Out-of-Pocket Maximum $6,000 $12,000
Family Coverage, 2 or more enrolled - per calendar Year
Deductible - per person/family $5000/$10000 $7000/$14000
Out-of-Pocket Maximum - per person/family $6000/$12000 $12000/$24000
(Medical and Pharmacy Included in the Out-of-Pocket Maximum)
INPATIENT SERVICES IN-NETWORK IN-NETWORK OUT-OF-NETWORK
4
Medical, Surgical and Hospice Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
4
Hospital Level Care at Home Covered 100% after Deductible Covered 100% after Deductible Not Covered
4
Skilled Nursing Facility - Up to 60 days per calendar Year Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
4
Inpatient Rehab Therapy: Physical, Speech, Occupational Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
Up to 40 days per calendar Year for all therapy types combined
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
PROFESSIONAL SERVICES IN-NETWORK IN-NETWORK OUT-OF-NETWORK
Office Visits & Minor Office Surgeries
1
Primary Care Provider (PCP) $20 $20 40% after Deductible
1
Primary Care Provider (PCP) Virtual Visits Covered 100% Covered 100% Not Covered
1
Specialist/Secondary Care Provider (SCP) $40 $40 40% after Deductible
Allergy Tests See Office Visits Above See Office Visits Above Not Covered
Allergy Treatment and Serum Covered 100% Covered 100% Not Covered
Major Surgery Covered 100% Covered 100% 40% after Deductible
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
PREVENTIVE SERVICES AS OUTLINED BY THE ACA2,3 IN-NETWORK IN-NETWORK OUT-OF-NETWORK
1
Primary Care Provider (PCP) Covered 100% Covered 100% Not Covered
1
Specialist/Secondary Care Provider (SCP) Covered 100% Covered 100% Not Covered
Adult and Pediatric Immunizations Covered 100% Covered 100% Not Covered
Elective Immunizations - herpes zoster (shingles), rotavirus Covered 100% Covered 100% Not Covered
Diagnostic Tests: Minor Covered 100% Covered 100% Not Covered
Other Preventive Services Covered 100% Covered 100% Not Covered
VISION SERVICES IN-NETWORK IN-NETWORK OUT-OF-NETWORK
Preventive Eye Exams Covered 100% Covered 100% Not Covered
All Other Eye Exams $40 $40 40% after Deductible
4
OUTPATIENT SERVICES IN-NETWORK IN-NETWORK OUT-OF-NETWORK
Outpatient Facility Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
Ambulatory Surgical Center Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
Imaging Center Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
Ambulance (Air or Ground) - Emergencies Only Covered 100% after Deductible See In-Network Benefit See In-Network Benefit
Emergency Room $150 after Deductible See In-Network Benefit See In-Network Benefit
®
Intermountain InstaCare Facilities, Urgent Care Facilities $50 $50 40% after Deductible
®
Intermountain KidsCare Facilities $20 $20 Not Available
®
Intermountain Connect Care Covered 100% Covered 100% Not Available
Radiation Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
Dialysis Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
2
Diagnostic Tests: Minor Covered 100% Covered 100% 40% after Deductible
2
Diagnostic Tests: Major Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
Home Health, Hospice, Outpatient Private Nurse Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
Outpatient Cardiac Rehab Covered 100% Covered 100% 40% after Deductible
Outpatient Rehab/Habilitative Therapy: Physical, Speech, Occupational $40 after Deductible $40 after Deductible 40% after Deductible
UT MPS-TIER 01/01/25 See other side for additional benefits
BOWEN COLLINS & ASSOCIATES G1022022 1001 L40M0882 01/01/2025
MEMBER PAYMENT SUMMARY
TIER 1 TIER 2 OUT-OF-
VALUE MED NETWORK
VALUE AND MED NETWORKS

MISCELLANEOUS SERVICES IN-NETWORK IN-NETWORK OUT-OF-NETWORK

4
Durable Medical Equipment (DME) Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
3
Miscellaneous Medical Supplies (MMS) Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
Autism Spectrum Disorder See Professional, Inpatient, See Professional, Inpatient, See Professional, Inpatient,
Outpatient, or Mental Health Outpatient, or Mental Health Outpatient, or Mental Health
and Chemical Dependency and Chemical Dependency and Chemical Dependency
4,7 See Professional, Inpatient or See Professional, Inpatient or 40% after Deductible
Maternity and Adoption
Outpatient Outpatient
2,4
Cochlear Implants or Auditory Osseointegrated Devices See Professional, Inpatient or See Professional, Inpatient or Not Covered
One device every 36 months per ear Outpatient Outpatient
Infertility - Select Services 50% after Deductible 50% after Deductible Not Covered
TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime See Professional, Inpatient or See Professional, Inpatient or Not Covered
Outpatient Outpatient
OPTIONAL BENEFITS IN-NETWORK IN-NETWORK OUT-OF-NETWORK
4
Mental Health and Substance Use Disorder
Office Visits $20 $20 40% after Deductible
Virtual Visits Covered 100% Covered 100% 40% after Deductible
Inpatient Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
Outpatient Covered 100% Covered 100% 40% after Deductible
2
Residential Treatment Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
Chiropractic $20 $20 Not Covered
(up to 20 visits per calendar Year)
4
Healthcare Provider Administered Injectable or Infusible Drugs Covered 100% after Deductible Covered 100% after Deductible 40% after Deductible
4 See Professional, Inpatient or See Professional, Inpatient or Not Covered
Bariatric Surgery (Up to one surgery/lifetime)
Outpatient Outpatient
PRESCRIPTION DRUGS
Pharmacy Deductible - Per Person per calendar Year $100
®
Prescription Drug List (formulary) RxSelect
4
Prescription Drugs - Up to 30 Day Supply of Covered Medications
Tier 1 $15
Tier 2 $30 after pharmacy Deductible
Ti 3
Tier f pharmacy
$50 after h D d ibl
Deductible
Tier 4 $100 after pharmacy Deductible
® 4
Maintenance Drugs - 90 Day Supply (Mail-Order, Retail90 )-selected drugs
Tier 1 $15
Tier 2 $60 after pharmacy Deductible
Tier 3 $150 after pharmacy Deductible
Generic Substitution Required Generic required or must pay Copay plus cost
difference between name brand and generic
1 Refer to [Link]/findadoctor to identify whether a Provider is a primary or secondary care Provider.
2 Refer to your Certificate of Coverage for more information.
3 Frequency and/or quantity limitations apply to some Preventive care and MMS Services.
4 Preauthorization is required for certain Services. Benefits may be reduced or denied if you do not preauthorize certain Services with Out-of-Network Providers. Please refer to
Section 11--" Healthcare Management", in your Certificate of Coverage, for details.
5 All Deductible/Copay/Coinsurance amounts are based on the Allowed Amount and not on billed charges. Out-of-Network Providers or Facilities may not accept the
Allowed Amount for Covered Services. When this occurs, you may be responsible for Excess Charges.
6 Certain Services as noted on this document and in your Certificate of Coverage are not subject to the Deductible.
7 SelectHealth provides a $4000 adoption indemnity as outlined by the state of Utah. Medical Deductible, Copay, or Coinsurance listed under the benefit applies and may exhaust
the benefits prior to any plan payments.
* Not applied to Medical Out-of-Pocket Maximum.
Select Health will cover an insulin from each therapeutic category with a cap of $25 per prescription of a 30-day supply.
All Covered Services obtained outside the United States, except for routine, Urgent, or Emergency conditions require preauthorization.

To contact Member Services, call 800-538-5038 weekdays, from 7:00 a.m. to 8:00 p.m., Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users should call 711.

UT MPS-TIER 01/01/25
08/23/24 [Link]