GroupHealth

GroupHealth HealthPays HSA 2000/4000 Catastrophic Benefits
	In-Network
Annual Deductible	$2,000 per Individual or $4,000 Family
Member Coinsurance	20%
Out-of-Pocket Limit⁺	$5,100 per member or $10,200 per family
Benefits	After deductible, member pays
Office Visits Including mental health outpatient services.	20%
Manipulative therapy Limit total visits PCY† to 10 combined for both in- and out-of-network.	20%
Acupuncture	20%, up to 8 visits PCY
Naturopathy	20%, up to 3 visits PCY
Maternity care	Not covered
Lab/X-ray Services	20%
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. Maternity care not covered.	20%
Devices, equipment & supplies (DME and prosthetics.)	Covered up to 50%
Prescription drugs	Not covered
Emergency care	20%
Vision Care	Not covered
	Deductible does not apply
Preventive care visits For children and adults, including physicals and immunizations, as established in GroupHealth’s preventive care schedule.	Covered in full

+ Member coinsurance and annual deductible 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