|
PCY = per calendar year |
|
Plan Name |
Welcome 500 |
Welcome 1750 |
Welcome 3500 |
|
Name of Network |
Group Health Network |
Annual Deductible
Per individual PCY;
the maximum deductible
per family equals 3 times
the individual amount
the deductible applies to all expenses unless otherwise specified |
$500 |
$1,750 |
$3,500 |
Annual Coinsurance Maximum
Per
individual PCY;
the maximum coinsurance per family
equals 3 times the individual
amount; once the coinsurance maximum is met, services are covered
in full |
$4,000 |
$6,000 |
$10,000 |
Out-of-Pocket Limit
Per
individual PCY;
includes annual
deductible and coinsurance maximum; the maximum out-of-pocket per
family equals 3 times the individual amount; once the out-of-pocket
limit is
met, services are covered in full |
$4,500 |
$7,750 |
$13,500 |
|
Lifetime Maximum |
$2 million per individual |
|
Shared
Outpatient Visits |
All visits
subject to
$30 copay per visit
First 5 shared visits (indicated by *) PCY paid at 100%
(with no deductible); following visits paid at 80% after annual
deductible |
No copay per visit
All visits paid at percentages shown below;
no deductible for first 5 shared
visits (indicated by *) PCY;
following visits paid after
annual deductible |
|
60% |
50% |
|
Office Visits* |
Covered as "Shared
Outpatient Visits" |
Preventive Care*
For children and
adults, including physicals and immunizations, as established in Group
Health's preventive care schedule |
Covered as "Shared
Outpatient Visits" |
Manipulative Therapy*
10 visits limit PCY |
Covered as "Shared
Outpatient Visits" |
Acupuncture*
8 visits limit
PCY |
Covered as "Shared
Outpatient Visits" |
Naturopathy*
3 visits limit PCY |
Covered as "Shared
Outpatient Visits" |
|
 |
|
PCY = per calendar year |
|
Plan Name |
Welcome 500 |
Welcome 1750 |
Welcome 3500 |
|
Name of Network |
Group Health Network |
Maternity Care - Outpatient*
Prenatal and
postpartum visits |
Covered as "Shared
Outpatient Visits" |
Not covered |
Mental Health Services -
Outpatient*
- 12 visits limit PCY |
Covered as "Shared
Outpatient Visits" |
Lab & X-Ray Services
Outpatient services |
First $500 PCY
paid
at 100%
(with no deductible);
following services paid at 80% after annual deductible |
60% |
50% |
Rehabilitation Services - Outpatient*
Outpatient physical,
occupational, and restorative speech-therapy services combined; 30
visits limit PCY |
Covered as "Shared
Outpatient Visits" |
Hospital Care - Inpatient
Hospital
room and board; inpatient surgery; anesthesia; intensive and coronary
care; laboratory tests; radiology services; drugs while in hospital |
80%
after $500 copay per day;
$2,500 (5 days) maximum
copay
per admission |
60% |
50% |
Maternity Care - Inpatient
Delivery & associated hospital care |
Covered same as
"Hospital Care - Inpatient" |
Not covered |
Mental Health Services -
Inpatient
- 12 days limit PCY |
Covered same as
"Hospital Care - Inpatient" |
Rehabilitation Services - Inpatient
Inpatient
physical, occupational, and restorative speech-therapy services
combined; 60 days limit PCY |
Covered same as
"Hospital Care - Inpatient" |
Prescription Drugs - Outpatient
No deductible
Drugs and medicines that
require a prescription, including injectables,
contraceptive drugs, devices and supplies.
Up to 30 day supply per copay |
You pay the
copay shown below
$20 generic
$40 brand-name
$3,000 annual benefit maximum
Mail order: $5 discount
for
30 day supply |
Not covered |
|
|
|
PCY = per calendar year |
|
Plan Name |
Welcome 500 |
Welcome 1750 |
Welcome 3500 |
|
Name of Network |
Group Health Network |
Ambulance Services
Emergency ground/air transportation |
80% |
60% |
50% |
Ambulance Services
Non-emergency ground/air
interfacility transfer |
80% for Group
Health-initiated transfers, except hospital-to-hospital transfers
covered in full |
60% for Group
Health-initiated transfers, except hospital-to-hospital transfers
covered in full |
50% for Group
Health-initiated transfers, except hospital-to-hospital transfers
covered in full |
Chemical Dependency Treatment - Inpatient
Limited to
acute detoxification only |
Covered same as
"Hospital Care - Inpatient" |
Chemical Dependency Treatment - Outpatient*
Limited to
diagnostic evaluation only |
Covered as "Shared
Outpatient Visits" |
Devices, Equipment & Supplies
(for home use)
Durable medical equipment,
orthopedic appliances, ostomy supplies, prosthetic devices, etc. |
50%
Maximum benefit is $2,500 PCY for all except
ostomy supplies and prosthetics;
maximum benefit PCY for ostomy supplies/prosthetics is $20,000 |
Emergency Care - GHC
At Group Health or
Group-Health designated facilities
$100 copay per incident |
80% |
60% |
50% |
Emergency Care - non-GHC
At non-Group Health or
non-Group Health designated facilities worldwide
$150 copay per incident |
80% |
60% |
50% |
Hearing Exams
(routine)*
To
determine hearing loss |
Covered as "Shared
Outpatient Visits" |
Home Health Care
No visit limit |
80% |
60% |
50% |
|
Hospice |
100% |
Organ Transplant
Six month benefit waiting
period |
Covered subject to
your applicable cost share up to $250,000
lifetime maximum (including
organ acquisition, matching, and donor costs
up to $50,000) |
Skilled Nursing Facility Care
60 days limit PCY |
80% |
60% |
50% |
|
|
|
PCY = per calendar year |
|
Plan Name |
Welcome 500 |
Welcome 1750 |
Welcome 3500 |
|
Name of Network |
Group Health Network |
Tobacco Cessation Sessions
Individual/group sessions |
100% |
Tobacco Cessation Pharmacy
Approved
pharmacy products |
Covered in full
when prescribed as part of a Group Health-designated tobacco cessation
program and dispensed through the Group Health mail order service |
Vision Care - Eye Exam*
Routine exam limited to
one visit
every 12 months |
Covered as "Shared
Outpatient Visits" |
Vision Care - Hardware
No deductible |
100% to $200
maximum benefit
every 12 months |
|
Work-Related Conditions |
Covered as for any
other condition (limited to partners, proprietors or corporate
officers who are not covered by a Workers' Compensation Act or other
similar law) |
|
Pre-Existing Conditions |
A pre-existing
condition is one for which there has been
diagnosis, treatment (including the use of prescribed drugs), or
medical advice within the six month period prior to the effective date
of coverage or a condition for which symptoms existed within the six
month period prior to the date of coverage and for which a prudent
person would have ordinarily sought treatment.
Pre-existing
conditions will not be
covered until a member has been continuously enrolled under this plan
for 9 (nine) months. In some cases, Group Health will apply credit for
pre-existing conditions if the person enrolling has been covered by a
prior group or individual health benefit plan that is considered
"creditable" coverage (i.e., a plan that had benefits as good or
better than this plan), at any time during the 63 (sixty-three) day
period immediately preceding the receipt date of the application. |
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