What comes out of my pay?How much will I pay out of my own pocket?What is Gold Cross contributing?What will I pay after I meet my deductible?Will my doctor be in-network?
Network Options: Select Med Plus Network or Select Care Plus Network
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
High Deductible Health Plan
Select Med Plus Network
High Deductible Health Plan
Select Med Plus Network
In-Network
Out-of-Network
Annual Deductible
You pay up to
$1,500 per individual
$3,000 per family
$1,500 per individual
$3,000 per family
You pay up to
$1,750 per individual
$3,500 per family
$1,750 per individual
$3,500 per family
Accumulator Period
January 1 – December 31
Coinsurance
You pay 20% AD
You pay 40% AD
Out-of-pocket Maximum
No more than
$3,000 per individual
$6,000 per family
$3,000 per individual
$6,000 per family
No more than
$4,500 per individual
$9,000 per family
$4,500 per individual
$9,000 per family
Preventive Services
You pay $0 according to government guidelines
Not covered
Office Visits
Primary Care
Specialist
Primary Care
Specialist
You pay
$15 AD
$25 AD
$15 AD
$25 AD
You pay
40% AD
40% AD
40% AD
40% AD
Mental Health Services
Office Visit
Inpatient
Office Visit
Inpatient
You pay
$15 AD
20% AD
$15 AD
20% AD
You pay
40% AD
40% AD
40% AD
40% AD
Emergency Services
Urgent Care
Emergency Room
Ambulance
Urgent Care
Emergency Room
Ambulance
You pay
$35 AD
$75 AD
20% AD
$35 AD
$75 AD
20% AD
You pay
40% AD
Covered as In-Network
Covered as In-Network
40% AD
Covered as In-Network
Covered as In-Network
Inpatient & Outpatient
Inpatient Hospital
Outpatient Surgery
Inpatient Hospital
Outpatient Surgery
You pay
20% AD
20% AD
20% AD
20% AD
You pay
40% AD
40% AD
40% AD
40% AD
Prescription Medication
Retail (30-day supply)
Mail Order (90-day supply)
Retail (30-day supply)
Mail Order (90-day supply)
You pay
Generic $7 AD / Preferred $21 AD / Non-preferred $42 AD / Specialty $100 AD
Generic $7 AD / Preferred $42 AD / Non-preferred $126 AD / Specialty N/A
Generic $7 AD / Preferred $21 AD / Non-preferred $42 AD / Specialty $100 AD
Generic $7 AD / Preferred $42 AD / Non-preferred $126 AD / Specialty N/A
Health Care Account
Health Savings Account (HSA)
Employee Cost Per Pay Period
Employee Only
$37.05
Employee + Spouse
$90.77
Employee + Child(ren)
$83.36
Employee + Family
$124.86
SelectHealth
High Deductible Health Plan
Select Care Plus Network
High Deductible Health Plan
Select Care Plus Network
In-Network
Out-of-Network
Annual Deductible
You pay up to
$1,500 per individual
$3,000 per family
$1,500 per individual
$3,000 per family
You pay up to
$1,750 per individual
$3,500 per family
$1,750 per individual
$3,500 per family
Accumulator Period
January 1 – December 31
Coinsurance
You pay 20% AD
You pay 40% AD
Out-of-pocket Maximum
No more than
$3,000 per individual
$6,000 per family
$3,000 per individual
$6,000 per family
No more than
$4,500 per individual
$9,000 per family
$4,500 per individual
$9,000 per family
Preventive Services
You pay $0 according to government guidelines
Not covered
Office Visits
Primary Care
Specialist
Primary Care
Specialist
You pay
$15 AD
$25 AD
$15 AD
$25 AD
You pay
40% AD
40% AD
40% AD
40% AD
Mental Health Services
Office Visit
Inpatient
Office Visit
Inpatient
You pay
$15 AD
20% AD
$15 AD
20% AD
You pay
40% AD
40% AD
40% AD
40% AD
Emergency Services
Urgent Care
Emergency Room
Ambulance
Urgent Care
Emergency Room
Ambulance
You pay
$35 AD
$75 AD
20% AD
$35 AD
$75 AD
20% AD
You pay
40% AD
Covered as In-Network
Covered as In-Network
40% AD
Covered as In-Network
Covered as In-Network
Inpatient & Outpatient
Inpatient Hospital
Outpatient Surgery
Inpatient Hospital
Outpatient Surgery
You pay
20% AD
20% AD
20% AD
20% AD
You pay
40% AD
40% AD
40% AD
40% AD
Prescription Medication
Retail (30-day supply)
Mail Order (90-day supply)
Retail (30-day supply)
Mail Order (90-day supply)
You pay
Generic $7 AD / Preferred $21 AD / Non-preferred $42 AD / Specialty $100 AD
Generic $7 AD / Preferred $42 AD / Non-preferred $126 AD / Specialty N/A
Generic $7 AD / Preferred $21 AD / Non-preferred $42 AD / Specialty $100 AD
Generic $7 AD / Preferred $42 AD / Non-preferred $126 AD / Specialty N/A
Health Care Account
Health Savings Account (HSA)
Employee Cost Per Pay Period
Employee Only
$47.95
Employee + Spouse
$117.47
Employee + Child(ren)
$107.87
Employee + Family
$161.57
