Unified Fire Authority Benefit Guide (1)_ (003) | Page 6

Medical Benefits
Administered by SelectHealth
Comprehensive healthcare provides peace of mind. In case of an illness or injury, you and your family are covered with an excellent medical plan through Unified Fire Authority.
Unified Fire Authority offers one medical plan design through SelectHealth that allows employees a choice between two networks- SelectHealth Med or SelectHealth Care. The base network is SelectHealth Med and the buy-up network is SelectHealth Care. With both networks employees may access IHC Facilities.
Both plans will provide access to providers from two tiers of networks which gives you additional flexibility and potential for cost savings. While there are two tiers of networks in each plan, you only have one deductible and out-of-pocket maximum to satisfy. You can move between Tier 1 and Tier 2 throughout the year as needed and the in-network costs spent between the two tiers will go towards your one deductible and out of pocket maximum.
The health plan deductible is based on a plan year; therefore your deductible will reset every July 1. Pre-authorizations are required for certain services.
Value Network
Care Network
Out-of-Network
SelectHealth Care and Value Networks
Tier 1
In-Network
Tier 2
Out-of-Network
Annual Deductible
( per person / family)
$ 1,000 / $ 2,000
$ 1,000 / $ 2,000
$ 2,000 / $ 4,000
Annual Out-of-Pocket Maximum
( per person / family)
$ 3,000 / $ 6,000
$ 3,000 / $ 6,000
$ 6,000 / $ 12,000
Coinsurance
20 % AD
20 % AD
40 %
DOCTOR’ S OFFICE
Office Visits( PCP / SCP)
$ 15 / $ 20 Copay
$ 15 / $ 20 Copay
40 % After Deductible
Preventive Care
Covered 100 %
Covered 100 %
Not Covered
PRESCRIPTION DRUGS
Retail – 30 day supply Tier 1
$ 10
Tier 2
$ 25
Tier 3
$ 45
Tier 4
$ 100
Retail or Mail Order – 90 day supply Maintenance Tier 1
$ 10
Maintenance Tier 2
$ 50
Maintenance Tier 3
$ 135
HOSPITAL SERVICES
Emergency Room
$ 75 After Deductible
Urgent Care
$ 30 Copay
$ 30 Copay
40 % After Deductible
Inpatient Services
20 % After Deductible
20 % After Deductible
40 % After Deductible
Outpatient Surgery
20 % After Deductible
20 % After Deductible
40 % After Deductible
Ambulance Service
20 % After Deductible
MENTAL HEALTH SERVICES
Office Visits
Covered 100 %
Covered 100 %
Covered 100 % After Deductible
Inpatient Services
20 % After Deductible
20 % After Deductible
40 % After Deductible
Outpatient Services
20 %
20 %
40 % After Deductible
SUBSTANCE ABUSE SERVICES
Office Visits
Covered 100 %
Covered 100 %
Covered 100 % After Deductible
Inpatient Services
20 % After Deductible
20 % After Deductible
40 % After Deductible
Outpatient Services
20 %
20 %
40 % After Deductible
OTHER SERVICES
Maternity Services
20 % After Deductible
20 % After Deductible
40 % After Deductible
Home Health Care
20 % After Deductible
20 % After Deductible
40 % After Deductible
Outpatient Rehab Therapy: Physical, Speech, Occupational
$ 20 After Deductible
$ 20 After Deductible
40 % After Deductible
Connect Care
Covered 100 %
Covered 100 %
Not Available
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