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Group Health Value
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Contact Information

Local Phone: 206-901-4636
Toll-Free Phone: 1-888-901-4636
TTY/TDD Phone: 711 or 1-800-833-6388
Find a Provider
Visit the Plan's Website

Benefit Summary

Annual Costs 2009 Coverage 2010 Coverage

Annual deductible

Medical Services:
Enrollee pays $100 per person/$300 per family (three or more people)

Annual deductible does not apply to some benefits, including preventive care.

Prescription drugs:
None

$350/person
$1,050/family

Annual out-of-pocket maximum

Enrollee pays $1,500 per person/$3,000 per family

$2,000/person
$6,000/family

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 (not subject to annual deductible)

20%

Emergency room (copay waived if admitted)

$75 copay per visit (not subject to annual deductible)

$75

Hearing

    

(routine annual exam)

$15 copay per exam

$30

(hardware)

$800 maximum plan payment every 36 consecutive months for hearing aid and rental/repair (not subject to annual deductible)

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)

$300/day ($900 max/year per person)

(outpatient)

$150 copay for facility fees per surgery or procedure; surgeon, anesthesiologist, etc., covered in full

$100

Mental health care

   

(outpatient)

$15 copay per visit, up to 50 visits per year

$30

Obstetric care

    

(inpatient)

Enrolle pays inpatient hospital copay for mother only

$300/day ($900 max/year)

(outpatient)

Covered in full

Enrollee pays $0

Office visits

$15 copay per visit

$30

Physical, occupational, and speech therapy (per-visit cost for 60 visits/year combined)

Inpatient
Includes massage therapy

Enrollee pays inpatient hospital copay, up to 60 days per year

Outpatient
Includes massage therapy
$15 copay per visit, up to 60 visits per year for all therapies combined

 

$30

Prescriptions

    

tier 1 (retail pharmacy, 30-day supply)

Not subject to annual deductible

Formulary generic, all insulin, and all disposable diabetic supplies, $10 copay

$20

tier 2 (retail pharmacy, 30-day supply)

Not subject to annual deductible

Formulary brand-name drugs, $30 copay

$40

tier 3 (retail pharmacy, 30-day supply)

N/A

$60

tier 1 (mail order, 90-day supply)

Not subject to annual deductible

Formulary generic, all insulin, and all disposable diabetic supplies, $20 copay

$40

tier 2 (mail order, 90-day supply)

Not subject to annual deductible

Formulary brand-name drugs, $60 copay

$80

tier 3 (mail order, 90-day supply)

N/A

$120

Preventive care

Covered in full (not subject to annual deductible)

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)

$15 copay per visit, up to 10 visits per year

$30

Vision care

    

(annual exam)

$15 copay per exam; one eye exam every 12 consecutive months

$30

(glasses and contact lenses)

$150 maximum plan payment every 2 calendar years for frames, lenses, contacts, and fitting fees combined (not subject to annual deductible)

Enrollee pays any costs above $150 every 24 months for frames, lenses, contacts, and fitting fees combined