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GroupHealth Cooperative -
Welcome Plan Benefits
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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
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Welcome 750 Plan |
Welcome 1820 Plan |
Welcome 3500 Plan |
Annual Deductible
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$750 per person or
$2,250 per family |
$1,820 per person or
$5,460 per family |
$3,500 per person or
$10,500 per family |
| Member Coinsurance |
20% |
40% |
50% |
| Out-of-Pocket Limit** |
$4,000 per person
$12,000 per family |
$6,000 per person
$18,000 per family |
$10,000 per person
$30,000 per family |
| Lifetime Maximum Benefits
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$2,000,000 |
$2,000,000 |
$2,000,000 |
| Benefits |
After deductible, member pays |
After deductible, member pays |
After deductible, member pays |
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First 5 visits covered with just a copayment. Deductible and coinsurance do not apply until after the 5th
visit for services (indicated by †) |
First 5 visits you pay 40% coinsurance. Your
deductible does not apply until after the 5th visit
for services (indicated by ‡). |
First 5 visits you pay 50% coinsurance. Your
deductible does not apply until after the 5th visit
for services (indicated by ‡). |
Office visits
Includes urgent care and mental health outpatient services. |
† $30/visit + 20% |
‡ 40% |
‡ 50% |
Preventive Care
For children and adults, including physicals and immunizations, as
established in Group Health's preventive care schedule. |
† $30/visit + 20% |
‡ 40% |
‡ 50% |
| Manipulative therapy |
† $30/visit, up to 10 visits PCY † |
‡ 40%, up to 10 visits PCY † |
‡ 50%, up to 10 visits PCY † |
| Acupuncture |
† $30/visit, up to 8 visits PCY |
‡ 40%, up to 8 visits PCY |
‡ 50%, up to 8 visits PCY |
| Naturopathy |
† $30/visit, up to 3 visits PCY |
‡ 40%, up to 3 visits PCY |
‡ 50%, up to 3 visits PCY |
Maternity care
Outpatient non-routine prenatal and postpartum visits. Copay waived for routine outpatient care.
Delivery and associated hospital care. |
† $30 + 20%
$500 per day to 5 days/admit + 20% |
Not covered |
Not covered |
| Lab/X-ray Services |
Deductible waived on first $500 PCY, then deductible and 20% apply. |
40% |
50% |
Hospital Visits - Inpatient
Hospital room and board; inpatient surgery; anesthesia; intensive and coronary
care; laboratory tests; radiology services; drugs while in hospital. |
$500 per day to 5 days/admit +
20% coinsurance. |
40% |
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) |
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) |
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) |
Prescription drugs - Outpatient
Drugs and medicines that require a prescription, including injectables,
contraceptive drugs, devices, and supplies. |
$20 copay generic/ $40 copay brand for a 30-day supply
or less. $3,000 annual benefit maximum. Not subject to the deductible.
Mail order; $5 discount for each 30-day supply. |
Not Covered |
Not Covered |
Emergency care
Provided at Group Health or Group Health–designated hospital emergency
departments. |
$100 + 20% |
$100 + 40% |
$100 + 50% |
Emergency care
Provided at non-Group Health facilities. |
$150 + 20% |
$150 + 40% |
$150 + 50% |
| Vision Care |
† $30 + 20% for routine eye exam and
$200 hardware benefit per 12 month period.
Hardware not subject to deductible or coinsurance. |
‡40% for routine eye exam and $200
hardware benefit per 12 month period.
Hardware not subject to deductible or coinsurance. |
‡50% for routine eye exam and $200
hardware benefit per 12 month period.
Hardware not subject to deductible or coinsurance. |
+ 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
