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Home My WebLink AboutCity of Twin Falls Select Health Benefits FY 2025 CITY OF I 0/0 0 - i- Select MEMBER V# Health IN-NETWORK O T-O RNETWORK S E L E C T H EALT H NETWORK/H SA Q Ll4L I F I E D when using In-Network Providers,you are responsible When using Out-of-Network Providers,you are to pay the amounts in this column. responsible to pay the amounts in this column. w• UAL D •• (TIBLE ANDMED UAL •UTO ILPO • r•IRK • • • RK Self Only Coverage,1 person enrolled-per plan Year Deductible $2,500 $ 2,750 Out-of-Pocket M axim un$ 4,000 $ 5,500 Family Coverage,2 or more enrolled-per plan Year Deductible $5,000 $ 5,500 Out-of-Pocket Maxim un$ 8,000 $ 11,000 (M edical and Pharm ay Included in the Out-of-Pocket M axim un) •RK • • • RK Medical,Surgical and Hospice 20%after Deductible 4 0%after Deductible Skilled Nursing Facility4-Up to 60 days per plan Year 20%after Deductible 4 0%after Deductible Inpatient Rehab Therapy:Physical,Speech,Occupational 20%after Deductible 4 0%after Deductible Up to 40 days per plan Year for all therapy types com lined Physician's Fees-(Malical,Surgical,Maernity,Anesthesia) 20%after Deductible 4 0%after Deductible Office Visits&Minor Office Surgeries Primary Care Provider(PCP)1 $15 after Deductible 4 0%after Deductible Primary Care Provider(PCP)Virtual Visitsl Covered 100%after Deductible 4 0%after Deductible Specialist/Secondary Care Provider(SCP)I $25 after Deductible 4 0%after Deductible Allergy Tests See Office Visits Above 5 0%after Deductible Allergy Treatm ait and Serum 2 0%after Deductible 5 0%after Deductible Major Surgery 20%after Deductible 4 0%after Deductible Physician's Fees-(Malical,Surgical,Mdernity,Anesthesia) 20%after Deductible 4 0%after Deductible PREVENMVE SERVICES AS • •• Prim ay Care Provider(PCP)I Covered 100%5 0%after Deductible Specialist/Secondary Care Provider(SCP)1 Covered 100%5 0%after Deductible Adult and Pediatric Lin in nizations C overed 100%5 0%after Deductible Elective Im in nizations-herpes zoster(shingles),rotavirus C overed 100%5 0%after Deductible Diagnostic Tests:Minor C overed 100%5 0%after Deductible Other Preventive Services Covered 100% 50%after Deductible VISIONSERVICESO RK • • • ' Preventive Eye Exam s Overed 100%5 0%after Deductible All Other Eye Exam s $5 after Deductible 4 0%after Deductible • •RK • Outpatient Facility and Am bxlatory Surgical 2 0%after Deductible 4 0%after Deductible Am hilance(Air or Ground)-Emergencies Only 20%after Deductible S ee hi-Network Benefit Em agency Room $75 after Deductible S ee In-Network Benefit Urgent Care Facilities $ 35 after Deductible 4 0%after Deductible Intermountain Connect Care Covered 100%after Deductible S ee Professional,Inpatient,Outpatient, or Miscellaneous Services Radiation 20%after Deductible 4 0%after Deductible Dialysis 20%after Deductible 4 0%after Deductible Diagnostic Tests:Minor 2 Covered 100%after Deductible 4 0%after Deductible Diagnostic Tests:Major 20%after Deductible 4 0%after Deductible Hom eHealth,Hospice,Outpatient Private Nurse 2 0%after Deductible 4 0%after Deductible Outpatient Cardiac Rehab C overed 100%after Deductible 4 0%after Deductible Outpatient Rehab/Habilitative Therapy:Physical,Speech,Occupational $ 25 after Deductible 4 0%after Deductible ID-MPS HDHP 01/01/24 See other side for additional benefits 10 CITY OF I tI - i- Select MEMBER V# Health IN-NETWORK O T-O RNETWORK SELECTHEALTH NETWORK/HSA Q LALIFIED •• • + • • • IRK Durable Medical Equipm ait(DME)4 20%after Deductible 4 0%after Deductible Miscellaneous Medical Supplies(M M S)3 20%after Deductible 4 0%after Deductible Autism Spectrum Disorder See Professional,Inpatient,Outpatient,or See Professional,Inpatient,Outpatient,or Mental Health and Chem i al Dependency Mental Health and Chem i al Dependency Services Services M aternity4 See Professional,Inpatient or Outpatient 40%after Deductible Cochlear Im liants,Hearing Aids,or Auditory Osseointegrated Devices2'4 See Professional,Inpatient or Outpatient 5 0%after Deductible One device every 36 months per ear. Up to 45 language/speech therapy visits during the 12 months after the delivery of the covered device. Infertility-Select Services 50%after Deductible 5 0%after Deductible TMI(Tem poromandibular Joint)Services-Up to$2,000 lifetime See Professional,Inpatient or Outpatient 5 0%after Deductible • Pr10 N A,BEN EFITS I T U N N ErWO IRK • • FLN FTWO RK Mental Health and Chem i al Dependency (combined benefits) Office Visits $15 after Deductible 4 0%after Deductible Virtual Visits Covered 100%after Deductible 4 0%after Deductible Inpatient 20%after Deductible 4 0%after Deductible Outpatient 20%after Deductible 4 0%after Deductible Residential Treatm elt2 20%after Deductible 4 0%after Deductible Chiropractic $30 after Deductible 40%after Deductible (up to 20 visits per plan Year) Injectable Drugs,Chemotherapy,and Specialty Medications 20%after Deductible 4 0%after Deductible Bariatric Surgery(Up to one surgery/lifetime)4 See Professional,Inpatient or Outpatient 4 0%after Deductible PRESCRIPTION • RU •. Prescription Drug List(form dary) RxSelecte Prescription Drugs-Up to 30 Day Supply of Covered MaBeationS 4 Tier 1 $7 after hi-Network Deductible Tier 2 $21 after In-Network Deductible Tier 3 $42 after In-Network Deductible Tier 4 $100 after In-Network Deductible Maintenance Drugs-90 Day Supply(Mdl-Order,Retai190®)-selected drugs 4 Tier 1 $7 after In-Network Deductible Tier 2 $42 after In-Network Deductible Tier 3 $126 after In-Network Deductible Deductible Waiver Certain prescription drugs are not subject to the Deductible Generic Substitution Required Generic required or m 1st pay Copay plus cost difference between nam ebrand and generic 1 Refer to selecthealth.org/findadoctor to identify whether a Provider is a prim ay or secondary care Provider. 2 Refer to your Certificate of Coverage form a-e inform aion. 3 Frequency and/or quantity lim Cations apply to som ePreventive care and M M S Services. 4 Preauthorization is required for certain Services.Benefits in ay be reduced or denied if you do not preauthorize certain Services with Out-of-Network Providers.Please refer to Section 11-2 Healthcare Managem ait",in your Certificate of Coverage,for details. 5 All Deductible/Copay/Coinsurance am aunts are based on the Allowed Am ant and not on billed charges.O it-of-Network Providers or Facilities may not accept the Allowed Am ant for Covered Services.When this occurs,you m ay be responsible for Excess Charges. 6 Certain Services as noted on this docum mt and in your Certificate of Coverage are not subject to the Deductible. All Covered Services obtained outside the United States,except for routine,Urgent,or Em agency conditions require preauthorization. To contact Menber 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. TTYusers should call 711. Benefits are administered and underwritten by SelectHealth,Inc.SM(domiciled in Utah). ID-MPS HDHP 01/01/24 03/14/24 selecthealth.org 11 17 Deductible Waived - Drugs, Devices, and Tests What's covered? Someof our High Deductible Health Plans (HDHPs) provide coverage for maintenance medications, devices, and tests before you m eet your deductible. J Below we've listed the m ost com m mly covered m edication, device, and test categories.To find out if your plan includes this benefit,call M ern ber Services. • A sthmaand COPD • C ardiovascular • C ardiovascular Antiadrenergics • C holesterol • Diabetes - Insulin • D iabetes - Non-Insulin • D iabetes -Testing Supplies • A nti-depressants • 0 steoporosis «� Questions? J / Call M em ber Services at 800-538-5038. 0 0 � 0' } v LargeSelect Em ployer M em ber Guide Idaho 2024 08/23