Deductible Medical Plan - Group Health

October 1, 2003 - September 30, 2004

Information provided is in summary format.  Any difference between the summary provided and actual contract will be settled in favor of the contract.

In-Network

Network

Group Health Providers

Deductible

$500 Individual/$1,500 Family

Coinsurance

80% after deductible

Out-of-Pocket Max

$2,000 Individual/$6,000 Family

Maximum Benefit

Unlimited

Office Visits

$20 copay, then 80% after deductible

Preventive Care (well baby care, well adult visits, following adult/child schedules)

$20 copay, then 100%

Deductible does not apply.

Diagnostic Lab & X-Ray

80% after deductible

Ambulance 

80%;  GHC initiated non-emergency transfers

covered at 100%

Deductible does not apply.

Hospital Inpatient

80% after deductible

Emergency Room*

GHC:  $75 copay (waived if admitted) Deductible and 80% coinsurance applies.

Non-GHC:  $125 copay.  Patient must notify GHC within 24 hours.  Deductible and 80% coinsurance applies.

Chiropractic - 10 visits/yr

$20 copay, then 80% after deductible

Rehabilitation:

     condition per calendar year

     Outpatient - 60 days/visits per

     condition per calendar year

$20 copay, then 80% after deductible

Mental Health:

     Outpatient - 20 visit/yr

$30 copay for individual session or

$20 copay for group session, then 80% after deductible

Chemical Dependency:

  $11,285 max in 24 month period

     Outpatient

$20 copay, then 80% after deductible

Prescription Drugs - Retail

(Participating Pharmacies)

Generic:  $15 copay

Brand Name:  $30 copay

30-day supply

Prescription Drugs - Mail Order

Generic:  $30 copay

Brand Name:  $60 copay

90-day supply

$20 copay
See the self-funded NBN Vision Plan Summary offered by the Seattle Public Schools to all eligible employees.