What comes out of my pay?How much will I pay out of my own pocket?What is Capstone Nutrition contributing?What will I pay after I meet my deductible?Will my doctor be in-network?
Network Options:
Select Med Network Traditional Plan or Select Med Network High Deductible Health Plan
You’ve built a trusting relationship and you want to keep it. But, did you know that you can also save money by using an in-network provider? That’s why you will be able to choose a provider network that is right for you and your family’s health and wellbeing.
(800) 538-5038 | selecthealth.org
Medical Plans
SelectHealth
Traditional PPO Plan
Select Med Network
Traditional PPO Plan
Select Med Network
In-Network *
Annual Deductible
You pay up to
$1,000 per individual
$1,000 per member / $2,000 per family
$1,000 per individual
$1,000 per member / $2,000 per family
Accumulator Period
January 1 – December 31
Coinsurance
You pay 20% AD
Out-of-pocket Maximum
No more than
$3,000 per individual
$3,000 per member / $6,000 per family
$3,000 per individual
$3,000 per member / $6,000 per family
Preventive Services
You pay $0 according to government guidelines
Office Visits
Primary Care
Specialist
Primary Care
Specialist
You pay
$30 co-pay
$50 co-pay
$30 co-pay
$50 co-pay
Mental Health Services
Office Visit
Inpatient
Office Visit
Inpatient
You pay
$30 co-pay
20% AD
$30 co-pay
20% AD
Emergency Services
Urgent Care
Emergency Room
Urgent Care
Emergency Room
You pay
$45 co-pay
$300 AD
$45 co-pay
$300 AD
Inpatient & Outpatient
Inpatient Hospital
Outpatient Surgery
Inpatient Hospital
Outpatient Surgery
You pay
20% AD
20% AD
20% AD
20% AD
Prescription Medication
Retail (30-day supply)
Pharmacy Deductible
Retail (30-day supply)
Pharmacy Deductible
You pay
Generic $15 / Preferred $35 APD / Non-preferred $60 APD / Specialty $200 APD
$100 per member per year
Generic $15 / Preferred $35 APD / Non-preferred $60 APD / Specialty $200 APD
$100 per member per year
Health Care Account
Flexible Spending Account (FSA)
AD: After Deductible
APD: After Pharmacy Deductible
* Benefits are paid for out-of-network providers. However, deductibles, out-of-pocket maximums, and coinsurance can be up to two times the in-network levels. Additionally, members will likely be balance-billed for any gap between what the plan pays for in-network providers and what an out-of-network provider charges. For more information, refer to plan documents.
APD: After Pharmacy Deductible
* Benefits are paid for out-of-network providers. However, deductibles, out-of-pocket maximums, and coinsurance can be up to two times the in-network levels. Additionally, members will likely be balance-billed for any gap between what the plan pays for in-network providers and what an out-of-network provider charges. For more information, refer to plan documents.
Employee Cost Per Pay Period
Employee Only
$56.34
Employee + One Dependent
$154.57
Employee + Family
$231.33
SelectHealth
High Deductible Health Plan (HDHP)
Select Med Network
High Deductible Health Plan (HDHP)
Select Med Network
In-Network *
Annual Deductible
You pay up to
$1,500 per individual
$3,000 per family
$1,500 per individual
$3,000 per family
Accumulator Period
January 1 – December 31
Coinsurance
You pay 20% AD
Out-of-pocket Maximum
No more than
$2,250 per individual
$4,500 per family
$2,250 per individual
$4,500 per family
Preventive Services
You pay $0 according to government guidelines
Office Visits
Primary Care
Specialist
Primary Care
Specialist
You pay
20% AD
20% AD
20% AD
20% AD
Mental Health Services
Office Visit
Inpatient
Office Visit
Inpatient
You pay
20% AD
20% AD
20% AD
20% AD
Emergency Services
Urgent Care
Emergency Room
Urgent Care
Emergency Room
You pay
20% AD
20% AD
20% AD
20% AD
Inpatient & Outpatient
Inpatient Hospital
Outpatient Surgery
Inpatient Hospital
Outpatient Surgery
You pay
20% AD
20% AD
20% AD
20% AD
Prescription Medication
Retail (30-day supply)
Pharmacy Deductible
Retail (30-day supply)
Pharmacy Deductible
You pay
Generic 20% AD / Preferred 20% AD / Non-preferred 20% AD / Specialty 20% AD
None included in Annual Deductible
Generic 20% AD / Preferred 20% AD / Non-preferred 20% AD / Specialty 20% AD
None included in Annual Deductible
Health Care Account
Health Savings Account (HSA)
Limited Purpose Flexible Spending Account (LPFSA)
Limited Purpose Flexible Spending Account (LPFSA)
AD: After Deductible
* Benefits are paid for out-of-network providers. However, deductibles, out-of-pocket maximums, and coinsurance can be up to two times the in-network levels. Additionally, members will likely be balance-billed for any gap between what the plan pays for in-network providers and what an out-of-network provider charges. For more information, refer to plan documents.
* Benefits are paid for out-of-network providers. However, deductibles, out-of-pocket maximums, and coinsurance can be up to two times the in-network levels. Additionally, members will likely be balance-billed for any gap between what the plan pays for in-network providers and what an out-of-network provider charges. For more information, refer to plan documents.
Employee Cost Per Pay Period
Employee Only
$30.01
Employee + One Dependent
$107.85
Employee + Family
$154.05
