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Select Health Medicare NoRx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Select Health Medicare NoRx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Select Health Medicare NoRx (HMO) in 2025, please refer to our full plan details page.
Select Health Medicare NoRx (HMO) is a HMO plan offered by Intermountain Health Care, Inc. available for enrollment in 2025 to people living in Davis, Salt Lake, Utah, and Weber Counties. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Select Health Medicare NoRx (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Select Health Medicare NoRx (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Select Health Medicare NoRx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $60.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6700.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
Prescription drugs are not covered by Select Health Medicare NoRx (HMO).
Additional Benefits
The Select Health Medicare NoRx (HMO) plan offers comprehensive coverage with a variety of benefits. The plan covers inpatient hospital stays with a $400 copay for days 1-5, and no copay for days 6-90, as well as outpatient services with copays ranging from $15 to $400 and coinsurance for some services. The plan also includes coverage for primary care, preventive services, hearing, vision, and dental services, with varying copays and maximum benefits. Additional benefits include ambulance services, emergency services, home health services with no copay, and skilled nursing facility care with no copay for some days. The plan also offers coverage for hearing aids and eyewear, as well as dental services. However, it is important to note that some services, such as certain types of hearing aids, specific dental procedures, and some rehabilitation services, may not be covered.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, but Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you pay a $400 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services, with a $40-$400 copay and 20% coinsurance, observation services with a $400 copay, ambulatory surgical center services with a $250 copay, and outpatient substance abuse services with a $15-$25 copay. Outpatient blood services are also covered, including services not usually covered by Medicare plans.
Partial Hospitalization See details
Partial Hospitalization is covered by the Select Health Medicare NoRx (HMO) plan with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Select Health Medicare NoRx (HMO) plan. Ground and Air Ambulance Services each have a $250 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Select Health Medicare NoRx (HMO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $35 copay, and Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $35 copay, and Worldwide Emergency Transportation has a $250 copay.
Primary Care See details
The Select Health Medicare NoRx (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $20 copay, physician specialist services with a $40 copay, mental health specialty services with a $25 copay for individual sessions and a $15 copay for group sessions, and podiatry services and other health care professional services with a copay between $0 and $40. This plan also includes coverage for psychiatric services with a $25 copay for individual sessions and a $15 copay for group sessions, physical therapy and speech-language pathology services with a $20 copay, additional telehealth benefits with a copay between $0 and $40, and opioid treatment program services with 10% coinsurance.
Preventive Services See details
The Select Health Medicare NoRx (HMO) plan covers preventive services, including Medicare-covered services with no copay. The plan also covers annual physical exams, health education, in-home safety assessments, medical nutrition therapy, weight management programs, fitness benefits, remote access technologies, home and bathroom safety devices and modifications, kidney disease education, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. However, the plan does not cover Personal Emergency Response Systems (PERS), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, and Counseling Services.
Hearing Services See details
Hearing Services include hearing exams with a $40 copay. Prescription hearing aids are covered with a copay between $299 and $1799, but inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $40 copay. Eyewear benefits include contact lenses and eyeglasses (lenses and frames), with a combined maximum benefit of $200 every year. Eyeglass lenses and frames are not covered.
Dental Services See details
The Select Health Medicare NoRx (HMO) plan covers Medicare dental services with a $40 copay, and other dental services with a maximum benefit of $1,500 per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services are covered with no copay, but fluoride treatment and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay, and the coinsurance is between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Select Health Medicare NoRx (HMO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, Prosthetics/Medical Supplies with a 20% coinsurance for Medicare-covered devices and supplies, and Diabetic Therapeutic Shoes/Inserts with a 20% coinsurance; Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a maximum copay of $40 and a coinsurance of at most 20%, and for Diagnostic Radiological Services with a maximum copay of $300.00. Therapeutic Radiological Services have a coinsurance of at most 20%, while Lab Services and Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by the Select Health Medicare NoRx (HMO) plan with no copay and no coinsurance, though prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services (Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services) are covered. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Select Health Medicare NoRx (HMO) plan, but require prior authorization. For days 1-20 and 56-100, there is no copay, but for days 21-55, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Select Health Medicare NoRx (HMO) plan does not cover acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. This plan covers Over-the-Counter (OTC) Items with no copay, and Meal Benefit with prior authorization.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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