SelectHealth Medicare NoRx (HMO)
H1994 - 016 - 0
(5 / 5)
SelectHealth Medicare NoRx (HMO) is a Medicare Advantage Plan by SelectHealth.
This page features plan details for 2023 SelectHealth Medicare NoRx (HMO) H1994 – 016 – 0 available in Davis, Salt Lake, Utah, and Weber Counties.
IMPORTANT: This page features the 2023 version of this plan. See the 2025 version using the link below:
Locations
SelectHealth Medicare NoRx (HMO) is offered in the following locations.
Plan Overview
SelectHealth Medicare NoRx (HMO) offers the following coverage and cost-sharing.
| Insurer: | SelectHealth |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,700 In-network |
| Drugs Covered: | No |
Ready to sign up for SelectHealth Medicare NoRx (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
SelectHealth Medicare NoRx (HMO) qualifies for a monthly Medicare Give Back Benefit of $50.00.
| Premium Reduction: | $50.00 |
Premium Breakdown
SelectHealth Medicare NoRx (HMO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $164.90 | $0.00 | $50.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
SelectHealth Medicare NoRx (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: Yes, contact plan for further details |
Dental (comprehensive)
| Diagnostic services: | 0% coinsurance (limits may apply) (authorization required) (referral not required) |
| Endodontics: | 0% coinsurance (limits may apply) (authorization required) (referral not required) |
| Extractions: | 0% coinsurance (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | 0% coinsurance (limits may apply) (authorization required) (referral not required) |
| Periodontics: | 0% coinsurance (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | 0% coinsurance (limits may apply) (authorization required) (referral not required) |
| Restorative services: | 0% coinsurance (limits may apply) (authorization required) (referral not required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | Not covered (no limits) |
| Oral exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $150 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | $0-40 copay or 0-20% coinsurance (authorization required) (referral not required) |
| Lab services: | $0 copay (authorization required) (referral not required) |
| Outpatient x-rays: | $0 copay (authorization required) (referral not required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $40 copay per visit (authorization not required) (referral not required) |
Emergency care/Urgent care
| Emergency: | $95 copay per visit (always covered) |
| Urgent care: | $30 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $40 copay (authorization not required) (referral not required) |
| Routine foot care: | $40 copay (limits may apply) (authorization not required) (referral not required) |
Ground ambulance
| $250 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | $399-1,699 copay (no limits) (authorization not required) (referral not required) |
| Hearing exam: | $0 copay (authorization not required) (referral not required) |
Hospital coverage (inpatient)
| $360 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) |
Hospital coverage (outpatient)
| $0-350 copay or 20% coinsurance per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $6,700 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $360 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) |
| Outpatient group therapy visit: | $15 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | $15 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | $25 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | $25 copay (authorization not required) (referral not required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | $20 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | $20 copay (authorization required) (referral not required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $196 per day for days 21 through 55 $0 per day for days 56 through 100 (authorization required) (referral not required) |
Transportation
| Not covered |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | Not covered (no limits) |
| Eyeglass lenses: | Not covered (no limits) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Routine eye exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for SelectHealth Medicare NoRx (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST