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GroupHealth Cooperative
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Index | Plan
Exclusions | Provider
List | Download Application
Benefit Schedules:
Balance 1250 | Balance 1750 | Balance
2500 | Balance
5000 | HealthPays™ | Welcome
Plans
Rate Schedules:
Balance 1250 | Balance 1750 | Balance 2500 | Balance 5000 | HealthPays™ | Welcome
Plans
| Balance 5000 Benefits |
Alliant Plus
In-network |
Alliant Plus
Out-of-network |
| Annual Deductible |
$5,000 per member or $15,000 per family |
| Member Coinsurance |
50% |
50% |
Out-of-Pocket Limit+
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$10,000 per person or
$30,000 per family |
| Lifetime Maximum Benefits
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$2,000,000 |
| Benefits |
No Deductible |
After deductible, member pays |
Office Visits
Including mental health outpatient services. |
$30/visit |
$30/visit |
Manipulative therapy
Limit total visits PCY† to 10 combined for both in- and out-of-network. |
$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 non-routine prenatal and postpartum visits. Copay waived for routine care. |
Not covered |
Not covered |
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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. |
$100 per day up to 5 days/admit + 50% |
$100 per day up to 5 days/admit + 50% |
| Lab/X-Ray Services |
Deductible waived on first $500 PCY, then deductible and 50% apply. |
50% |
Devices, equipment & supplies
(DME and prosthetics.) |
DME—50% up to $5,000 in charges ($2,500 max. benefit PCY);
Prosthetics—50% up to $40,000 in charges ($20,000 max. benefit PCY) |
| Emergency care |
$100 + 50% |
$150 + 50% |
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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
|
Not covered |
Not covered |
Vision Care
Hardware not covered. |
$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. 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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Assurant Health
