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GroupHealth - Electronic Application
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Benefit Schedules:
Balance 1750 | Balance
2500 | Balance
5000 | HealthPays 2750 | HealthPays 2000 | Welcome
Plans
Rate Schedules:
Balance 1750 | Balance 2500 | Balance 5000 | HealthPays 2750 | HealthPays 2000 | Welcome
Plans
| Balance 1750 Benefits |
Alliant Plus
In-network |
Alliant Plus
Out-of-network |
| Annual Deductible |
$1,750 per member or $5,250 per family |
| Member Coinsurance |
20% |
40% |
Out-of-Pocket Limit+
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$6,000 per person or $18,000 per family |
| Benefits |
No Deductible |
After deductible, member pays |
Office Visits
Including mental health outpatient services. |
Primary care: $30/visit
Specialty care: $50/visit |
Primary care: $30/visit + 40%, after deductible
Specialty care: $50/visit + 40%, after deductible |
Manipulative therapy
Limit total visits PCY† to 10 combined for both in- and out-of-network. |
$30/visit |
$30/visit |
| Acupuncture |
$30/visit, up to 8 visits PCY |
$30/visit |
| Naturopathy |
$30/visit, up to 3 visits PCY |
$30/visit |
Maternity care
Outpatient non-routine prenatal and postpartum visits. Copay waived for routine care. |
$30/visit |
$30/visit |
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After deductible, member pays |
Hospital Visits - Inpatient
Hospital room and board; inpatient surgery; anesthesia, intensive and coronary care; laboratory tests; radiology services; drugs while in hospital. Includes mental health inpatient treatment and
maternity care (delivery and associated hospital care). |
$300 per day up to 5 days/admit + 20%, after deductible |
$300 per day up to 5 days/admit + 40%, after deductible |
| Lab/X-Ray Services |
Deductible waived on first $400 per calendar year, then deductible and 20% apply |
40%, after deductible |
Devices, equipment & supplies
(DME and prosthetics.) |
DME—50%
Prosthetics—50% |
| Emergency care |
$100 + 30% |
$100 + 30% |
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Deductible does not apply |
Preventive Care
For children and adults, including physicals and immunizations, as established in Group Health's preventive care schedule. |
Covered in Full |
$30/visit
$300 individual/$600 family annual benefit maximum |
Prescription drugs
Outpatient: Drugs and medicines that require a prescription, including injectables, contraceptive drugs, devices, and supplies. |
$15 generic/40% brand-name/50% non-formulary |
$20 generic/40% brand-name/50% non-formulary |
Vision Care
$200 hardware benefit per 12 months.
Not subject to coinsurance. |
$30 for routine eye exam per 12 months |
$30 of eye exam fee reimbursed per 12 months |
+ Member coinsurance and emergency care copayment apply to out-of-pocket limit. Deductible does not apply to out-of-pocket limit.
† PCY = per calendar year
‡ Western Washington counties: King, Kitsap, Pierce, Snohomish, Island, Thurston, Whatcom, Skagit, San Juan, Mason, Lewis, and Gray’s Harbor (ZIP codes: 98541, 98557, 98559, & 98568).
Central/Eastern Washington counties: Kittitas, Yakima, Benton, Franklin, Walla Walla, Columbia, Whitman, and Spokane.
NOTE: This is a summary of benefits. The contents are not to be accepted or construed as a substitute for the provisions of the master policy or agreements. Other terms and conditions apply. All plans
cover on-the-job-injury-related health care costs for partners, proprietors, or corporate officers who are not covered by a workers’ compensation act, subject to the plan’s cost shares and
benefit limitations
Coverage provided by Group Health Cooperative
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