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Local: 206-901-4636
Toll-Free: 1-888-901-4636
TTY/TDD: 711 or 1-800-833-6388
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Benefits Booklet (Certificate of Coverage)
The 2012 benefits booklet will be posted as soon as they are available. If you have questions about the certificate of coverage, or to receive a copy, contact the plan.
Benefits Summary
| Annual Costs | 2012 Coverage |
|---|---|
| Member Pays | |
Deductible |
$1,400/individual |
Out-of-pocket maximum |
$5,100 individual/$10,200 family (must meet family out-of-pocket maximum before plan pays 100%) |
Prescription drug deductible |
Included in deductible |
| Medical Benefits | 2012 Coverage |
|---|---|
| Member Pays | |
Ambulance |
|
Per trip, air |
10% (Extended network 30%) |
Per trip, ground |
10% (Extended network 30%) |
Diagnostic tests, laboratory, and x-rays |
10% (Extended network 30%) |
Durable medical equipment, supplies, and prostheses |
10% (Extended network 30%) |
Emergency room (Copay waived if admitted) |
10% (Extended network 30%) |
Hearing |
|
Hardware |
Any amount over $800 every 36 months after deductable has been met for hearing aid and rental/repair combined. |
Routine annual exam |
10% (Extended network 30%) |
Home health |
10% (Extended network 30%) |
Hospital services |
|
Inpatient |
10% (Extended network 30%) |
Outpatient |
10% (Extended network 30%) |
Obstetric care |
|
Inpatient |
Information unavailable, contact your plan |
Outpatient |
Information unavailable, contact your plan |
Office visit |
|
Chemotherapy |
10% (Extended network 30%) |
Mental health |
10% (Extended network 30%) |
Primary care |
10% (Extended network 30%) |
Radiation |
10% (Extended network 30%) |
Specialist |
10% (Extended network 30%) |
Urgent care |
10% (Extended network 30%) |
Physical, occupational and speech therapy (Per-visit cost for 60 visits/year combined) |
10% (Extended network 30%) |
Prescription drugs |
|
Mail order (up to a 90-day supply) Value tier |
$10 (Extended network N/A) |
Mail order (up to a 90-day supply) Tier 1 |
$40 (Extended network N/A) |
Mail order (up to a 90-day supply) Tier 2 |
$80 (Extended network N/A) |
Mail order (up to a 90-day supply) Tier 3 |
50% up to $750 (Extended network N/A) |
Retail pharmacy (up to a 30-day supply) Value tier |
$5 |
Retail pharmacy (up to a 30-day supply) Tier 1 |
$20 |
Retail pharmacy (up to a 30-day supply) Tier 2 |
$40 |
Retail pharmacy (up to a 30-day supply) Tier 3 |
50% up to $250 |
Preventive care |
$0 (Extended network 30%); See certificate of coverage or check with plan for full list of services. |
Spinal manipulations |
10% (Extended network 30%) |
Vision care |
|
Exam (annual) |
10% (Extended network 30%) |
Glasses and contact lenses |
Any amount over $150 every 24 months (or two calendar years for UMP) for frames, lenses, contacts, and fitting fees combined. |
