PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
SelectHealth
CMS Rating
Not Rated
Plan Type
HMO-POS
Annual Deductible
$0.00

What To Know About This Plan

  • This plan has health and drug coverage

Plan Details

Costs and Other Important Information

Plan Year:
2014
Optional Supplemental Benefits?
Yes
Choice of Doctors?
Plan Doctors Only (some exceptions)
Prescription Drugs Covered?
Yes
Out-Of-Pocket Spending Limit
$3,900 In-Network$7,800 In and Out-of-Network
Other Deductibles?
In Network: No. Out of Network: No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
In Network
Out of Network
Doctor Office Visits
$5 maximum per visit. Point of Service: 30% maximum per visit
In Network: $5 maximum per visit. Point of Service: 30% maximum per visit
Specialist Office Visit
$40 maximum per visit. Point of Service: 30% maximum per visit
In Network: $40 maximum per visit. Point of Service: 30% maximum per visit
Outpatient Services
$200 maximum or 20% maximum per visit. Point of Service: 30% maximum per visit
In Network: $200 maximum or 20% maximum per visit. Point of Service: 30% maximum per visit
Emergency Care
$65 maximum per visit. Point of Service: Not Applicable
In Network: $65 maximum per visit. Point of Service: Not Applicable
Ambulance Services
$200 maximum. Point of Service: 30% maximum
In Network: $200 maximum. Point of Service: 30% maximum
Kidney Disease and Conditions
20% maximum per visit. Point of Service: 30% maximum per visit
In Network: 20% maximum per visit. Point of Service: 30% maximum per visit
Home Health Care
$0Point of Service: 30% maximum per visit
In Network: $0Point of Service: 30% maximum per visit
Durable Medical Equipment
20% maximum per item. Point of Service: 30% maximum per item
In Network: 20% maximum per item. Point of Service: 30% maximum per item
Inpatient Hospital Care
Days 1-7: $200 copay per day. Days 8-90: $0 copay per day. Point of Service: 30%
In Network: Days 1-7: $200 copay per day. Days 8-90: $0 copay per day. Point of Service: 30%
Skilled Nursing Facility (SNF)
Days 1-7: $0 copay per day. Days 8-20: $50 copay per day. Days 21-100: $100 copay per day. Point of Service: 30%
In Network: Days 1-7: $0 copay per day. Days 8-20: $50 copay per day. Days 21-100: $100 copay per day. Point of Service: 30%
Inpatient Mental Health Care
Days 1-7: $200 copay per day. Days 8-90: $0 copay per day. Point of Service: 30%
In Network: Days 1-7: $200 copay per day. Days 8-90: $0 copay per day. Point of Service: 30%

Cost Sharing Information

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$3 copay$3 copay$3 copay
Tier 2: Non-Preferred Generic$9 copay$9 copay$9 copay
Tier 3: Preferred Brand Name$45 copay$45 copay$45 copay
Tier 4: Non-Preferred Brand Name$95 copay$95 copay$95 copay
Tier 5: Specialty Tier33% coinsurance33% coinsurance33% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$9 copay$9 copay$9 copay
Tier 2: Non-Preferred Generic$27 copay$27 copay$27 copay
Tier 3: Preferred Brand Name$135 copay$135 copay$135 copay
Tier 4: Non-Preferred Brand Name$285 copay$285 copay$285 copay
Tier 5: Specialty Tier

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Not Rated
Colorectal cancer screening
Not Rated
Cholesterol screening for patients with heart disease
Not Rated
Glaucoma testing
Not Rated
Annual flu vaccine
Not Rated
Pneumonia vaccine
Not Rated
Improving or maintaining physical health
Not Rated
Improving or maintaining mental health
Not Rated
Monitoring physical ability
Not Rated
Access to primary care doctor visits
Not Rated
Adult BMI assessment
Not Rated

Managing Chronic Conditions

Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Not Rated
Diabetes care – eye exam
Not Rated
Diabetes care – kidney disease monitoring
Not Rated
Diabetes care – blood sugar controlled
Not Rated
Diabetes care – cholesterol controlled
Not Rated
Controlling blood pressure
Not Rated
Rheumatoid arthritis management
Not Rated
Improving bladder control
Not Rated
Reducing the risk of falling
Not Rated
Plan all-cause readmissions
Not Rated

Ratings of Plan Responsiveness and Care

Getting needed care
Not Rated
Getting appointments and care quickly
Not Rated
Customer service
Not Rated
Overall rating of health care quality
Not Rated
Overall rating of plan
Not Rated

Member Complaints, Problems Getting Services, and Choosing to Leave the Plan

Complaints about the health plan
Not Rated
Beneficiary access and performance problems
Members choosing to leave the plan
Not Rated
Plan makes timely decision about appeals
Not Rated
Reviewing appeals decisions
Not Rated
Call center – foreign language interpreter and TTY/TDD availability
Not Rated

Physician Finder

Physicians that accept SelectHealth Advantage (HMO-POS) for Utah

/
VALENTINE, CHRISTOPHER
4052 PIONEER PKWY
WEST VALLEY CITY, UT 84120
MILES, JEFFREY
3725 W 4100 S
WEST VALLEY CITY, UT 84120
FEIL, MATTHEW
3460 PIONEER PKWY
WEST VALLEY CITY, UT 84120
KOLBER, SHARON
3460 PIONEER PKWY
WEST VALLEY CITY, UT 84120
COLE, DAVID
3460 PIONEER PKWY
WEST VALLEY CITY, UT 84120
LARSEN, BRENT
3460 PIONEER PKWY
WEST VALLEY CITY, UT 84120
PUTNAM, CATHEY
3460 PIONEER PKWY
WEST VALLEY CITY, UT 84120
NICHOLLS, CHAD
3460 PIONEER PKWY
WEST VALLEY CITY, UT 84120
AGRESTA, MATTHEW
3451 S 5600 W
SALT LAKE CITY, UT 84120
SAIDI, ABDUL
3460 PIONEER PKWY
SALT LAKE CITY, UT 84120
THORN, TRENTON
3460 PIONEER PKWY
WEST VALLEY CITY, UT 84120
GRANGE, TIMOTHY
4052 PIONEER PKWY
SALT LAKE CITY, UT 84120
PERRY, ROGER
3460 PIONEER PKWY
WEST VALLEY CITY, UT 84120
WEBER, QUINN
3460 PIONEER PKWY
WEST VALLEY CITY, UT 84120
CHRISTENSEN, QUINN
134 W 2025 S CIRCLE
ST GEORGE, UT 84170
HAROLD, EMILY
1525 W 2100 S
SALT LAKE CITY, UT 84119
ANDERSON, LAURA
1525 W 2100 S
SALT LAKE CITY, UT 84119
Details
CHRISTOPHER VALENTINE, M.D.
Phone Number
(801) 840-2200
Office Locations
4052 PIONEER PKWY
WEST VALLEY CITY, UT 84120
4052 PIONEER PKWY WEST VALLEY CITY UT, 84120

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