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Local Phone: 206-901-4636
Toll-Free Phone: 1-888-901-4636
TTY/TDD Phone: 711 or 1-800-833-6388
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Benefit Summary
| Annual Costs | 2009 Coverage | 2010 Coverage |
|---|---|---|
Annual deductible |
None |
$250/person |
Annual out-of-pocket maximum |
Enrollee pays $750 per person/$1,500 per family |
$2,000/person |
Annual prescription drug deductible |
Does not apply |
Does not apply |
| Medical Benefits | 2009 Coverage | 2010 Coverage |
|---|---|---|
Ambulance services |
||
(air) |
$100 copay per trip |
$100/trip |
(ground) |
$75 copay per trip |
$75/trip |
Diagnostic tests, laboratory, and X-rays |
Covered in full |
Enrollee pays $0 |
Durable medical equipment, supplies, and prostheses |
Enrollee pays 20% coinsurance |
20% |
Emergency room (copay waived if admitted) |
$75 |
$75 |
Hearing |
||
(routine annual exam) |
$10 copay per exam |
$25 |
(hardware) |
$800 maximum plan payment every 36 consecutive months for hearing aid and rental/repair |
Enrollee pays any costs above $800, allowed every 36 months for hearing aid and rental/repair combined |
Hospital services |
||
(inpatient) |
$200 copay per day (maximum $600 per person per calendar year for all inpatient services combined) |
$200/day ($600 max/year per person) |
(outpatient) |
$100 copay for facility fees per surgery or procedure; surgeon, anesthesiologist, etc., covered in full |
$100 |
Mental health care |
||
(outpatient) |
$10 copay per visit, up to 50 visits per calendar year |
$25 |
Obstetric care |
||
(inpatient) |
Enrollee pays inpatient hospital copay for mother only |
$200/day ($600 max/year) |
(outpatient) |
Covered in full |
Enrollee pays $0 |
Office visits |
$10 copay per visit |
$25 |
Physical, occupational, and speech therapy (per-visit cost for 60 visits/year combined) |
Inpatient Enrollee pays inpatient hospital copay, up to 60 days per year Outpatient |
$25 |
Prescriptions |
||
tier 1 (retail pharmacy, 30-day supply) |
Formulary generic, all insulin, and all disposable diabetic supplies, $10 copay |
$20 |
tier 2 (retail pharmacy, 30-day supply) |
Formulary brand-name drugs, $30 copay |
$40 |
tier 3 (retail pharmacy, 30-day supply) |
N/A |
$60 |
tier 1 (mail order, 90-day supply) |
Formulary generic, all insulin, and all disposable diabetic supplies, $20 copay |
$40 |
tier 2 (mail order, 90-day supply) |
Formulary brand-name drugs, $40 copay |
$80 |
tier 3 (mail order, 90-day supply) |
N/A |
$120 |
Preventive care |
Covered in full |
Enrollee pays $0 (See Certificate of Coverage or check with plan for full list of services) |
Spinal manipulations (per-visit cost for 10 visits/year) |
$10 copay per visit, up to 10 visits per year |
$25 |
Vision care |
||
(annual exam) |
$10 copay per exam; one eye exam every 12 consecutive months |
$25 |
(glasses and contact lenses) |
$150 maximum plan payment once every 2 calendar years for frames, lenses, contacts, and fitting fees combined |
Any costs above $150 every 24 months for frames, lenses, contacts, and fitting fees combined |
