|
GroupHealth - Electronic Application
Index | Plan
Exclusions | Optional Dental | Provider
List | Download Application
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
| |
Welcome 750 |
Welcome 2000 Catastrophic Plan |
Welcome 3500 Catastrophic Plan |
Annual Deductible
|
$750 per member or $2,250 per family |
$2,000 per person or
$6,000 per family |
$3,500 per person or
$10,500 per family |
| Member Coinsurance |
20% |
40% |
50% |
| Out-of-Pocket Limit** |
$4,000 per member
$12,000 per family |
$6,000 per person
$18,000 per family |
$10,000 per person
$30,000 per family |
| Benefits |
After deductible, member pays |
After deductible, member pays |
After deductible, member pays |
| |
First 4 visits: You pay only your copayment for primary and specialty care visits. Your
deductible and coinsurance do not apply until after the 4th visit for certain services (indicated by ‡). |
First 4 visits: You pay only your copayment for primary and specialty care visits. Your
deductible and coinsurance do not apply until after the 4th visit for certain services (indicated by ‡). |
First 4 visits: You pay only your copayment for primary and specialty care visits. Your
deductible and coinsurance do not apply until after the 4th visit for certain services (indicated by ‡). |
Office visits
Includes urgent care and mental health outpatient services. |
Primary care: $30 + 20% ‡
Specialty care: $50 + 20% ‡ |
Primary care: $30 + 40% ‡
Specialty care: $50 + 40% ‡ |
Primary care: $30 + 50% ‡
Specialty care: $50 + 50% ‡ |
Preventive Care
For children and adults, including physicals and immunizations, as
established in Group Health's preventive care schedule. |
Covered in full, deductible waived |
Covered in full, deductible waived
|
Covered in full, deductible waived
|
| Manipulative therapy |
‡ $30 + 20%, up to 10 visits PCY |
‡ 40%, up to 10 visits PCY † |
‡ 50%, up to 10 visits PCY † |
| Acupuncture |
‡ $30 + 20%, up to 8 visits PCY |
‡ 40%, up to 8 visits PCY |
‡ 50%, up to 8 visits PCY |
| Naturopathy |
‡ $30 + 20%, 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%
Delivery & associated hospital care:
$500 per day to 5 days/admit + 20% |
Not covered |
Not covered |
| Lab/X-ray Services |
Deductible waived on first $400 PCY,
then deductible and 20% apply. |
Deductible waived on first $200 per calendar year, then
deductible and 40% apply |
Deductible waived on first $200 per calendar year, then
deductible and 50% apply |
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% |
40% |
50% |
Devices, equipment & supplies
(DME and prosthetics.) |
Covered up to 50% |
Covered up to 50% |
Covered up to 50% |
Prescription drugs - Outpatient
Drugs and medicines that require a prescription, including injectables,
contraceptive drugs, devices, and supplies. |
$15 copay generic/30% brand-name
Not subject to deductible
Mail order: $5 discount for 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. |
$100 + 20% |
$100 + 40% |
$100 + 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. 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.
|
Download Census 
