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Local Phone: 206-901-4636
Toll-Free Phone: 1-888-901-4636
TTY/TDD Phone: 1-800-833-6388
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Benefit Summary
| Medical Benefit | Coverage |
|---|---|
|
Lifetime maximum |
None |
|
Annual deductible |
None |
|
Annual out-of-pocket maximum |
Enrollee pays $750 per person/$1,500 per family for network benefits (Expenses as defined in the Certficate of Coverage do not count toward the out-of-pocket maximum.) |
|
Office and clinic visits |
$10 copay per visit |
|
Ambulance services |
|
|
(air) |
$100 copay per trip |
|
(ground) |
$75 copay per trip |
|
Bariatric Surgery (preauthorization required) |
Must be accepted into presurgical program; can only use plan-designated providers. Covered at same level as inpatient/outpatient and office/clinic visits; preauthorization required. |
|
Chemical dependency services (inpatient) |
Enrollee pays inpatient hospital copay |
|
Chemical dependency services (outpatient) |
$10 copay per treatment |
|
Diabetic education |
$10 copay per visit |
|
Diagnostic testing |
Covered in full |
|
Durable medical equipment, supplies, and prostheses |
Enrollee pays 20% coinsurance |
|
Emergency room (copay waived if admitted directly to hospital) |
$75 copay per visit |
|
Hearing |
|
|
(examination) |
$10 copay per exam |
|
(hardware) |
$300 maximum plan payment every 36 consecutive months for hearing aid and rental/repair when authorized |
|
Home health care |
Covered in full |
|
Hospice care (including respite care) |
Covered in full for terminally ill enrollees up to six months |
|
Hospital services |
|
|
(inpatient) |
$200 copay per day (maximum $600 per person per calendar year) |
|
(outpatient) |
$100 copay for facility fees per surgery or procedure; surgeon, anesthesiologist, etc., covered in full |
|
Massage therapy |
Included in physical, occupational, and speech therapy benefit |
|
Mental health care |
|
|
(inpatient) |
Enrollee pays inpatient hospital copay |
|
(outpatient) |
$10 copay per visit, up to 50 visits per year |
|
Neurodevelopmental therapy (for children ages 6 and younger) |
|
|
(inpatient) |
Enrollee pays inpatient hospital copay, up to 60 days per year |
|
(outpatient) |
$10 copay per visit, up to 60 visits per year for all therapies combined |
|
Obstetric and well-newborn care |
|
|
(inpatient) |
Enrollee pays inpatient hospital copay for mother only |
|
(professional services) |
Covered in full |
|
Organ transplants |
|
|
(inpatient) |
Enrollee pays inpatient hospital copay; preauthorization required |
|
(professional) |
Covered in full; preauthorization required Bone marrow donor searches covered in full, up to 15 searches per person per transplant |
|
Physical, occupational, speech, and massage therapies |
|
|
(inpatient) |
Enrollee pays inpatient hospital copay, up to 60 days per year Includes massage therapy |
|
(outpatient) |
$10 copay per visit, up to 60 visits per year for all therapies combined Includes massage therapy |
|
Prescription drugs, insulin, and disposable diabetic supplies |
Retail (up to a 30-day supply):
Mail order (up to a 90-day supply):
|
|
Preventive care |
Covered in full, subject to plan schedule |
|
Radiation and chemotherapy services |
Covered in full |
|
Skilled nursing facility care (150 days per benefit period) |
Enrollee pays inpatient hospital copay; covered up to 150 days per year (additional coverage may be approved if it substitutes for hospitalization) |
|
Spinal manipulations |
$10 copay per visit, up to 10 self-referred visits per year; preauthorization required for more than 10 visits |
|
Temporomandibular joint (TMJ) disorder |
Enrollee pays 50% coinsurance for inpatient and outpatient treatment, maximum plan payment of $1,000 per year (orthognathic surgery not covered) |
|
Vision |
|
|
(examinations) |
$10 copay per exam; one annual eye exam |
|
(hardware) |
$150 maximum plan payment once every two calendar years for frames, lenses, contacts, and fitting fees combined |
