What comes out of my pay?How much will I pay out of my own pocket?What is Crumbl Cookies contributing?What will I pay after I meet my deductible?Will my doctor be in-network?
Network Options: Select Value and Select Med Networks
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
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Medical Plans |
Traditional $1,500 Copay Plan
With this Traditional $1,500 PPO Plan you will only have access to both the Select Value Network and the Select Med Network. An important thing to know about this plan is that both the family deductible and family out-of-pocket maximum are embedded. This means that on a family plan each covered member must meet their individual deductible — up to the maximum family deductible — and each covered member has an individual out-of-pocket maximum — up to the family out-of-pocket maximum.
With this Traditional $1,500 PPO Plan you will only have access to both the Select Value Network and the Select Med Network. An important thing to know about this plan is that both the family deductible and family out-of-pocket maximum are embedded. This means that on a family plan each covered member must meet their individual deductible — up to the maximum family deductible — and each covered member has an individual out-of-pocket maximum — up to the family out-of-pocket maximum.
Please check with SelectHealth to see if your provider is in either the Select Value Network or the Select Med Network so that you can take advantage of greater discounts on care for you and your family.
| TRADITIONAL $1,500 COPAY PLAN VALUE & MED NETWORKS |
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|---|---|---|
| In-Network | Out-of-Network* | |
| Annual Deductible Embedded June 1 — May 31 |
You pay up to $1,500 per individual $1,500 per member / $3,000 per family |
You pay up to $3,000 per individual $3,000 per member / $6,000 per family |
| Coinsurance | You pay 10% AD | You pay 50% AD |
| Out-of-pocket Maximum Embedded June 1 — May 31 |
No more than $4,500 per individual $4,500 per member / $9,000 per family |
No more than $10,000 per individual $10,000 per member / $20,000 per family |
| Preventive Services | You pay $0 according to government guidelines | Not Covered |
| Office Visits Primary Care Specialist Virtual Vists |
You pay $30 copay $30 copay Covered 100% |
You pay 50% AD 50% AD Not Covered |
| Mental Health Services Office Visit Inpatient |
You pay $30 copay 10% AD |
You pay 50% AD 50% AD |
| Emergency Services Urgent Care Emergency Room |
You pay $75 copay $250 copay, AD |
You pay 50% AD Covered as In-Network |
| Inpatient & Outpatient Inpatient Hospital Outpatient Surgery |
You pay 10% AD 10% AD |
You pay 50% AD 50% AD |
| Prescription Medication Retail (30-day supply) Mail Order (90-day supply) |
Tier 1 / Tier 2 / Tier 3 / Tier 4 You pay $10 / $25 / $45 / $100 You pay up to 2.5x retail |
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$3,300 High Deductible Health Plan (HDHP)
With this $3,300 High Deductible Health Plan you will only have access to both the Select Value Network and the Select Med Network. An important thing to know about this plan is that both the family deductible and family out-of-pocket maximum are embedded. This means that on a family plan each covered member must meet their individual deductible — up to the maximum family deductible — and each covered member has an individual out-of-pocket maximum — up to the family out-of-pocket maximum.
With this $3,300 High Deductible Health Plan you will only have access to both the Select Value Network and the Select Med Network. An important thing to know about this plan is that both the family deductible and family out-of-pocket maximum are embedded. This means that on a family plan each covered member must meet their individual deductible — up to the maximum family deductible — and each covered member has an individual out-of-pocket maximum — up to the family out-of-pocket maximum.
Please check with SelectHealth to see if your provider is in either the Select Value Network or the Select Med Network so that you can take advantage of greater discounts on care for you and your family.
| $3,300 HIGH DEDUCTIBLE HEALTH PLAN VALUE & MED NETWORKS |
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|---|---|---|
| In-Network | Out-of-Network* | |
| Annual Deductible
Embedded |
You pay up to $3,300 per individual $3,300 per member / $6,600 per family |
You pay up to $6,000 per individual $6,000 per member / $12,000 per family |
| Coinsurance | You pay 20% AD | You pay 50% AD |
| Out-of-pocket Maximum Embedded June 1 — May 31 |
No more than $6,000 per individual $6,000 per member / $12,000 per family |
No more than $9,450 per individual $9,450 per member / $18,900 per family |
| Preventive Services | You pay $0 according to government guidelines |
Not Covered |
| Office Visits Primary Care Specialist UHC Telemedicine |
You pay 20% AD 20% AD Covered 100% |
You pay 50% AD 50% AD Not Covered |
| Mental Health Services Office Visit Inpatient |
You pay Covered 100% AD 20% AD |
You pay 50% AD 50% AD |
| Emergency Services Urgent Care Emergency Room |
You pay 20% AD 20% AD |
You pay 50% AD Covered as In-Network |
| Inpatient & Outpatient Inpatient Hospital Outpatient Surgery |
You pay 20% AD 20% AD |
You pay 50% AD 50% AD |
| Prescription Medication Retail (30-day supply) Mail Order (90-day supply) |
Tier 1 / Tier 2 / Tier 3 / Tier 4 You pay $10 AD / $25 AD / $45 AD / $100 AD You pay up to 2.5x retail |
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