|
Benefits |
Group Health Cooperative
Catastrophic Plan |
|
Network Provider |
Annual Deductible
per calendar year
Your
choice of three amounts |
$1,500 per person
$4,500 per family |
$2,500 per person
$7,500 per family
or
$5,000 per person
$15,000 per family |
|
Lifetime Maximum |
$2,000,000 per person |
Annual Out-of-Pocket Maximum
Per calendar year; deductible
not included; after the
out-of-pocket maximum is satisfied, network providers are covered at
100% |
$4,000 per person
$12,000 per family |
$6,000 per person
$18,000 per family
with $2,500 annual deductible
or
$10,000 per person
$30,000 per family
with $5,000 annual deductible |
Preventive Care Visits
Well-child and
well-adult care, including physicals and immunizations, as established
in Group Health's preventive care schedule |
100%
(not subject to deductible) |
Medical Center Visits
Office
visits; laboratory tests; diagnostic radiology services |
80% |
70% |
Hospital Care
Hospital
room and board; inpatient surgery; anesthesia; intensive and coronary
care; laboratory tests; radiology services; drugs while in hospital |
80% |
70% |
|
Outpatient Prescription Drugs |
Not covered |
|
Maternity Care |
Not covered |
Emergency Care
Provided
at Group Health or Group-Health designated hospital emergency
departments |
100% after $100
copay per incident
after annual deductible is met |
Emergency Care
Provided
at non-Group Health facilities |
100% after $150
copay per incident
after annual deductible is met |
Ambulance
Emergency transportation |
80% |
70% |
Devices, Equipment & Supplies
Medical
equipment, glucose monitors, ostomy supplies, etc. |
50% |
Routine Hearing Exams
To
determine hearing loss |
80% |
70% |
Mental Health Services
Inpatient
and outpatient services |
Not covered |
Chemical Dependency Treatment - Inpatient
Limited to
acute detoxification only |
80% |
70% |
Chemical Dependency Treatment - Outpatient
Limited to
diagnostic evaluation |
Not covered except
for diagnostic evaluation only.
80% |
Not covered except
for diagnostic evaluation only.
70% |
Smoking Cessation
Individual/group sessions |
Covered |
Smoking Cessation
Nicotine
replacement therapy |
Not covered |
Orthopedic Appliances
When
prescribed by a Group Health provider and listed in the Orthopedic
Appliance Formulary |
50%*
(not subject to deductible) |
Manipulative Therapy
(spinal manipulations)
Limited to
10 visits per person, per calendar year |
80% |
70% |
Acupuncture
Limited to
5 visits per diagnosis per person, per calendar year |
80% |
70% |
Naturopathy
Limited to
2 visits per diagnosis per person, per calendar year |
80% |
70% |
|
Work Related Conditions |
Covered (if not
covered by other plans/programs) |
Routine Eye Exams
Limited to
once every 12 months |
80% |
70% |
|
Vision Hardware |
Not covered |
Rehabilitation Services - Inpatient
Inpatient
physical, occupational, and restorative speech-therapy services
combined. |
80%
Limited
to 60 days per condition
per calendar year |
70%
Limited
to 60 days per condition
per calendar year |
Rehabilitation Services - Outpatient
Outpatient
physical, occupational, and restorative speech-therapy services
combined. |
80%
Limited to 30 days per condition
per calendar year |
70%
Limited to 30 days per condition
per calendar year |
|
Home Health Care |
80% |
70% |
Pre-Existing Conditions
A condition for
which there has been a diagnosis, treatment (including prescribed
drugs), or medical advice within the six month period prior to the
effective date of coverage. Services related to these conditions will
not be covered until the applicant has been continuously covered for
nine months under the plan. |
Pre-existing
conditions are not covered until a member has been continuously
enrolled under a Group Health plan for nine months, unless the date of
application is within 90 days of termination of prior similar
coverage. |
