selecthealth.org
In-Network Medical Benefits
Medical Deductible: None
Preventive Care: $0
Primary Care: $25
Specialty Care: $40
Connect Care
SM
: $10
Urgent Care Clinic: $40
Emergency Room: $350
Pharmacy Benefits
Rx Deductible: $150
Tier 1: $10
Tier 2: 25%
Tier 3: 50% After Rx Deductible
Tier 4: 20% After Rx Deductible
Tier 5: 20% After Rx Deductible
RX BIN: 015938
RX PCN: 7463
RX GRP ID: U1000009
© 2022 SelectHealth. All rights reserved. 11583551 10/22
Medical ID Card Guide
Use the ID card information below and the linked
samples (for Utah, Idaho, Nevada, and all other
states) to help you identify SelectHealth® members
and their network.
Members can
view, email,
and fax ID
card images
using the
SelectHealth
mobile app.
COMMERCIAL NETWORKS
SELECTHEALTH MEDICARE
SELECTHEALTH COMMUNITY CARE®
SAMPLE
SELECTHEALTH
NETWORKS
ID Card Back
Includes medical
and pharmacy
benefit information,
UHSS/Payer/Group
numbers, and
Provider Services/
Preauthorization
contact numbers
Only the state-issued Medicaid ID card
is required for SelectHealth Community
Care members to access services.
Verify eligibility at medicaid.utah.gov/
eligibility-lookup-tool or by calling
AccessNow at 801-538-6155.
The subscriber’s ID card covers all enrolled dependents.
Jonathan Doe
ADVANTAGE NETWORK
Member Services: 855-442-9900 (toll-free) TTY: 711
Find a Doctor: 800-515-2220
P.O. Box 30196, Salt Lake City
UT 84130-0196
ID: 800000000
SUBSCRIBER
HMO CSNP H1994 002
Find key information on the Member’s ID card front and back. Download 2022 Member ID card samples for:
Utah Idaho Nevada All Other States
ID Card Front
Includes network,
ID number, and
SelectHealth
contact
information
Medical Benefits
Out of Pocket Max: $3000
Medical Deductible: $1500
Primary Care: 20%*
Connect Care
SM
: 0%*
Urgent Care: 20%*
Pharmacy Benefits
Formulary: RxCore BIN: 800008
Rx: $10*/20%*/20%*/30%*
*After Medical Deductible
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Urgent or Emergency Services Outside of Utah:
Nevada Idaho
SelectHealth
Med
Urgent or emergency Services Outside of Utah, Idaho, and Nevada:
Provider Services: 888-830-0179
Preauthorization: 844-749-7833
Group: 78-800218
uhss.umr.com
UHSS ID: 776 800000000
Payor ID: 39026
UnitedHealthcare Shared Services | PO Box 30783, Salt Lake City, UT 84130
SAMPLE
ID: 800000000
SUB_FIRSTNAME A SUB_LASTNAME
SUBSCRIBER
Member Services: 800-538-5038
Find a Doctor: 800-515-2220
selecthealth.org
P.O. Box 30192
Salt Lake City, UT 84130-0192
CARE NETWORK
SAMPLE
Our Member Services representatives can answer your questions about
benefits and eligibility: Call us at 800-538-5038 weekdays, from 7:00 a.m.
to 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m.
