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GroupHealth Cooperative
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Benefit Schedules:
Balance 1000 | Balance 1500 | Balance 2500 | Balance 5000 | HealthPays™ | Welcome
Plans
Rate Schedules:
Balance 1000 | Balance 1500 | Balance 2500 | Balance 5000 | HealthPays™ | Welcome
Plans
| Balance 2500 Benefits |
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Alliant Plus
In-network |
Alliant Plus
Out-of-network |
| Annual Deductible |
$2,500 per member or $7,500 per family |
| Member Coinsurance |
40% |
40% |
Out-of-Pocket Limit+
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$8,000 per person or
$24,000 per family |
| Lifetime Maximum Benefits
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$2,000,000 |
| Benefits |
No Deductible |
After deductible, member pays |
| Office visits |
$30/visit |
$30/visit |
| Manipulative therapy |
$30/visit, up to 10 visits PCY † |
$30/visit, up to 10 visits PCY |
| Acupuncture |
$30/visit, up to 8 visits PCY |
$30/visit |
| Naturopathy |
$30/visit, up to 3 visits PCY |
$30/visit |
Maternity care
Outpatient prenatal and postpartum visits |
Not covered |
Not covered |
Mental health services
Outpatient services: Limit total visits PCY to 12 combined for both in- and out-of-network. |
$30/visit |
$30/visit |
| Lab/X-ray Services |
Covered in full |
Covered in full |
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After deductible, member pays |
Maternity care
Outpatient prenatal and postpartum visits |
40% |
40% |
Mental health services
Inpatient services: Limit total visits PCY to 12 combined for both in- and out-of-network. |
40% |
40% |
Hospital Visits - Inpatient
Hospital room and board; inpatient surgery; anesthesia; intensive and coronary
care; laboratory tests; radiology services; drugs while in hospital. |
40% |
40% |
| Emergency care |
$100 + 40% |
$150 + 40% |
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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. |
$30/visit |
$30/visit
$300 individual/$600 family annual benefit maximum |
Prescription drugs
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Not covered |
Not covered |
Vision Care
$200 hardware benefit per 12 months.
Not subject to coinsurance. |
$30 for routine eye exam |
$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, 98554, & 98568). Central/Eastern Washington counties: Kittitas,
Yakima, Benton, Franklin, Walla Walla, Columbia, Whitman, and Spokane.
* When three or more children are covered, the first two up to age 25 are billed.
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. Lifetime benefit maximum of $2 million applies to
all plans. 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 Options, Inc.
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Asuris
NW Health