Bookmark & ShareContact Information
Employees
Local Phone: 425-670-3000
Toll-Free Phone: 1-800-762-6004
TTY/TDD Phone: 1-888-923-5622 or 360-923-2701
Find a Provider
Visit the Plan's Website
Retirees
Local Phone: 425-686-1350
Toll-Free Phone: 1-800-352-3968
TTY/TDD Phone: 1-888-923-5622 or 360-923-2701
Find a Provider
Visit the Plan's Website
Benefit Summary
| Annual Costs | 2009 Coverage | 2010 Coverage |
|---|---|---|
Annual deductible |
Medical Services: Annual deductible does not apply to some benefits, including preventive care. Brand-name prescription drug deductible: |
$250/person |
Annual out-of-pocket maximum |
Enrollee pays $1,500 per person/$3,000 per family |
$2,000/person |
Annual prescription drug deductible |
$100/person |
$100/person |
| Medical Benefits | 2009 Coverage | 2010 Coverage |
|---|---|---|
Ambulance services |
||
(air) |
Enrollee pays 20% coinsurance |
20%/trip |
(ground) |
Enrollee pays 20% coinsurance |
20%/trip |
Diagnostic tests, laboratory, and X-rays |
Enrollee pays 10% coinsurance |
15% |
Durable medical equipment, supplies, and prostheses |
Enrollee pays 10% coinsurance |
15% |
Emergency room (copay waived if admitted) |
$75 copay per visit, then enrollee pays 10% coinsurance for physician and other professional provider fees |
$75 + 15% |
Hearing |
||
(routine annual exam) |
Covered in full under preventive care benefit; one exam per calendar year |
Enrollee pays $0 |
(hardware) |
$800 maxiumum plan payment every three calendar years for hearing aid, and rental/repair combined |
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), plus 10% coinsurance for professional services |
$200/day ($600 max/year per person) + 15% |
(outpatient) |
Enrollee pays 10% coinsurance |
15% |
Mental health care |
||
(outpatient) |
Enrollee pays 10% coinsurance per visit, up to 50 visits per year |
15% |
Obstetric care |
||
(inpatient) |
Enrolle pays inpatient hospital copay for mother only |
$200/day ($600 max/year) + 15% |
(outpatient) |
Enrollee pays 10% coinsurance |
15% |
Office visits |
Enrollee pays 10% coinsurance |
15% |
Physical, occupational, and speech therapy (per-visit cost for 60 visits/year combined) |
Inpatient Includes neurodevelopmental therapy Enrollee pays inpatient hospital copay Outpatient Includes neurodevelopmental therapy Enrollee pays 10% coinsurance per visit, up to 60 visits per calendar year |
15% |
Prescriptions |
||
tier 1 (retail pharmacy, 30-day supply) |
Up to a 90-day supply for both retail and mail order (annual prescription-drug deductible applies only to Tier 2 and Tier 3 drugs) (generic): 10% coinsurance Note: Tier 1 and 2 drugs purchased through a network retail pharmacy have a prescription cost-limit of $75 per 30-day supply. |
10% (90-day supply) |
tier 2 (retail pharmacy, 30-day supply) |
Up to a 90-day supply for both retail and mail order (annual prescription-drug deductible applies only to Tier 2 and Tier 3 drugs) (preferred brand): 30% Note: Tier 1 and 2 drugs purchased through a network retail pharmacy have a prescription cost-limit of $75 per 30-day supply. |
30% (90-day supply) |
tier 3 (retail pharmacy, 30-day supply) |
Up to a 90-day supply for both retail and mail order (annual prescription-drug deductible applies only to Tier 2 and Tier 3 drugs) (nonpreferred brand): 50% coinsurance *Enrollees pay more for Tier 3 drugs that have a generic equivalent. The plan pays as if the enrollee purchased the generic; the enrollee pays the rest |
50% (90-day supply, may also be subject to an ancillary charge) |
tier 1 (mail order, 90-day supply) |
$10 copay |
$10 |
tier 2 (mail order, 90-day supply) |
$50 copay |
$50 |
tier 3 (mail order, 90-day supply) |
$100 copay *Enrollees pay more for Tier 3 drugs that have a generic equivalent. The plan pays as if the enrollee purchased the generic; the enrollee pays the rest |
$100 (may also be subject to an ancillary charge) |
Preventive care |
Covered in full (not subject to annual medical 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) |
Enrollee pays 10% coinsurance, up to 10 visits per year |
15% |
Vision care |
||
(annual exam) |
Enrollee pays 10% coinsurance; one annual eye exam (not subject to annual medical deductible) |
15% |
(glasses and contact lenses) |
$150 maximum plan payment every two calendar years for frames, lenses, contacts, and fitting fees combined (not subject to annual medical deductible) |
Enrollee pays any costs above $150 every two calendar years for frames, lenses, contacts, and fitting fees combined |
