MEDICAL
SelectHealth

800-538-5038

Group #: G1021985

Full-time employees who actively work at least 30 hours per week are eligible for medical benefits, along with their legal spouse, dependent children up to age 26, and children of any age if they depend on the employee for support due to a disability. Coverage for new hires begins on the first of the month following their date of hire. Go back to Employee Benefits

Employee Premiums

Medical premiums for both traditional and high-deductible health plans (HDHP) are based on your participation level and earned status in the wellness program. Please see the Wellness Program section of the website for more information.

Plan & Wellness Program Participation

Single
(Per Pay Period)

Two-Party
(Per Pay Period)

Family
(Per Pay Period)

Plan & Wellness Program Participation

Traditional (Not Participating in Wellness Program)

Single (Per Pay Period): $80.00

Two-Party (Per Pay Period): $162.50

Family (Per Pay Period): $228.00

Traditional (Participating in Wellness Program)

Single (Per Pay Period): $57.50

Two-Party (Per Pay Period): $117.00

Family (Per Pay Period): $164.00

HDHP (Not Participating in Wellness Program)

Single (Per Pay Period): $59.00

Two-Party (Per Pay Period): $119.50

Family (Per Pay Period): $167.50

HDHP (Participating in Wellness Program)

Single (Per Pay Period): $42.00

Two-Party (Per Pay Period): $85.50

Family (Per Pay Period): $121.00

Plan Information

Stampin’ Up! offers two types of health plans: a traditional plan and a high-deductible health plan. It is up to you and your family to determine which plan is best suited for your healthcare needs.

Traditional Plan

Traditional Plan

In-Network Services from out-of-network providers are not covered (except emergencies)

Employee-Only Coverage

Deductible

$750

Out-of-Pocket Maximum

$3,000

Two-Party or Family Coverage

Deductible

$750 per person/$1,500 per family

Out-of-Pocket Maximum

$3,000 per person/$6,000 per family

Inpatient Services

Medical, Surgical, and Hospice

$20% after deductible

Skilled Nursing Facility (Up to 60 days)

20% after deductible

Inpatient Rehab Therapy (Up to 40 days)

20% after deductible

Professional Services

Primary Care Provider (PCP)

$25

Secondary Care Provider (SCP)

$40

Allergy Treatment and Serum

20%

Major Surgery

20%

Physician’s Fees (Medical, Surgical, Maternity, Anesthesia)

20% after deductible

Preventive Services

Covered 100%

Vision Services

Preventive Exams

Covered 100%

All Other Exams

$40

Outpatient Services

Outpatient Facility and Ambulatory Surgical

20% after deductible

Ambulance (Air or Ground) emergencies only

20% after deductible

Emergency Room (In Network)

$250 after deductible

Emergency Room (Out of Network)

$250 after deductible

Urgent Care Facilities

$50

Intermountain KidsCare Facilities

$25

Intermountain Connect Care

$10

Chemotherapy, Radiation, and Dialysis

20% after deductible

Diagnostic Tests (Minor)

Covered 100%

Diagnostic Tests (Major)

20% after deductible

Home Health, Hospice, and Outpatient Private Nurse

20% after deductible

Outpatient Rehab Therapy

$40 after deductible

Mental Health and Chemical Dependency

Office Visits

$25

Inpatient

20% after deductible

Outpatient

20%

Residential Treatment

20% after deductible

Prescription Drugs

Retail Pharmacy

Tier 1 / Tier 2 / Tier 3 / Tier 4
$15 / $30 / $50 / $100

Maintenance Drugs (90‑Day, Mail‑Order Supply)

Tier 1 / Tier 2 / Tier 3 / Tier 4
$15 / $60 / $150

Injectable Drugs and Specialty Medications

20% after deductible

High-Deductible Health Plan

High-Deductible Health Plan

In-Network Services from out-of-network providers are not covered (except emergencies)

Employee-Only Coverage

Deductible

$2,000

Out-of-Pocket Maximum

$3,000

Two-Party or Family Coverage

Deductible

$4,000

Out-of-Pocket Maximum

$3,000 per person/$6,000 per family

Inpatient Services

Medical, Surgical, and Hospice

$20% after deductible

Skilled Nursing Facility (Up to 60 days)

20% after deductible

Inpatient Rehab Therapy (Up to 40 days)

20% after deductible

Professional Services

Primary Care Provider (PCP)

$15 after deductible

Secondary Care Provider (SCP)

$25 after deductible

Allergy Treatment and Serum

20% after deductible

Major Surgery

20% after deductible

Physician’s Fees (Medical, Surgical, Maternity, Anesthesia)

20% after deductible

Preventive Services

Covered 100%

Vision Services

Preventive Exams

Covered 100%

All Other Exams

$25 after deductible

Outpatient Services

Outpatient Facility and Ambulatory Surgical

20% after deductible

Ambulance (Air or Ground) emergencies only

20% after deductible

Emergency Room (In Network)

$75 after deductible

Emergency Room (Out of Network)

$75 after deductible

Urgent Care Facilities

$35 after deductible

Intermountain KidsCare Facilities

$15 after deductible

Intermountain Connect Care

$10 after deductible

Chemotherapy, Radiation, and Dialysis

20% after deductible

Diagnostic Tests (Minor)

Covered 100% after deductible

Diagnostic Tests (Major)

20% after deductible

Home Health, Hospice, and Outpatient Private Nurse

20% after deductible

Outpatient Rehab Therapy

$25 after deductible

Mental Health and Chemical Dependency

Office Visits

$15 after deductible

Inpatient

20% after deductible

Outpatient

20% after deductible

Residential Treatment

20% after deductible

Prescription Drugs *AD (After deductible)

Retail Pharmacy

Tier 1 / Tier 2 / Tier 3 / Tier 4
$7 AD* / $21 AD / $42 AD / $100 AD

Maintenance Drugs (90‑Day, Mail‑Order Supply)

Tier 1 / Tier 2 / Tier 3 / Tier 4
$7 AD / $42 AD / $126 AD

Injectable Drugs and Specialty Medications

20% after deductible

Please Note: Preauthorization is required for certain services. Benefits may be reduced or denied if you do not preauthorize certain services. Please refer to the Certificate of Coverage for details.

Please see the Member Payment Summary and Certificate of Coverage for each plan to fully understand coverage and the differences between the two plans. The information here is intended solely to provide you with a brief description of your benefit options. The specific provisions in our contract will govern any and all claims or coverage issues.

Network Information

Employees working in the Riverton office should use providers and facilities in the SelectHealth Share network. Due to the number of providers available in Kanab and the surrounding areas, employees working in the Kanab office should use providers in the larger SelectHealth Med network.

To find an in-network provider, go to www.selecthealth.org/findadoctor and select the appropriate network. It is your responsibility to confirm that a provider will accept SelectHealth insurance and is a member of the correct network when you make your appointment.

Intermountain Connect Care

Connect Care is another option for accessing convenient, high‑quality urgent care whenever and wherever you need it. You can use your smartphone, tablet, or computer to connect with an Intermountain Healthcare clinician 24 hours a day, every day of the year.

Commonly treated conditions include stuffy and/or runny nose, allergies, sinus pain and pressure, eye infections, cough, painful urination, lower back pain, joint pain or strains, and minor skin problems.

You can create a Connect Care account and connect with a provider online or by downloading the app from the App Store or Google Play.

Cost of a Connect Care Consultation*

Cost of a Connect Care Consultation*

Traditional Plan

$10 copay per visit

High-Deductible Health Plan

$49 per visit until deductible is met; $10 copay per visit after deductible

*If the provider cannot diagnose your condition and states that you need to be seen in person, you will not be charged for the Connect Care visit.

Intermountain Health Answers

Health Answers is a nurse line that allows you to speak to a registered nurse who will listen to your concerns, answer medical questions, and help you decide what course of action to take. You can connect with a nurse 24 hours a day, every day of the year by calling 844‑501‑6600.

Resources

Summary of Benefits Coverage (all plans)
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Share (Riverton) Member Payment Summary - HDHP
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Share (Riverton) Member Payment Summary - Traditional
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Med (Kanab) Member Payment Summary - HDHP
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Med (Kanab) Member Payment Summary - Traditional
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NATIONCARE (KANAB) MEMBER PAYMENT SUMMARY – TRADITIONAL
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NATIONCARE (KANAB) MEMBER PAYMENT SUMMARY – HDHP
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Prescription Drug List
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Intermountain Home Delivery Pharmacy
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