|
HMO 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.
|
|
Policy
Number |
008700 |
|
|
In-Network |
|
HMO Network |
Group
Health Providers
|
|
Deductible |
N/A
|
|
Coinsurance |
N/A
|
|
Out-of-Pocket Limit |
$2,000
Individual/$4,000
Family
|
|
Maximum
Benefit |
Unlimited
|
|
Office
Visits |
$20 copay
|
|
Preventive
Care |
$20 copay |
|
Lab
Work |
100%
|
|
Ambulance
|
80%
|
|
Hospital
Inpatient |
100% |
|
Emergency
Room |
$75
copay at Group Health Facility (waived if admitted)
$125
copay at Non-Group Health Facility
(Not
waived) |
|
Maternity
|
Hospital: 100%
Physician: $20 copay per visit |
|
Chiropractic
- 10 visits/yr |
$20 copay
|
|
Rehabilitative Therapy |
|
|
Inpatient - 60 days per
condition per calendar year
|
100% |
|
Outpatient - 60 visits per
condition per calendar year
|
$20 copay
|
|
Mental
Health:
|
|
|
Inpatient - 12 days/yr |
80% |
|
Outpatient - 20 visits/yr
|
$20
copay per individual/family/couple visit;
$10 copay per
group visit |
|
Chemical
Dependency:
$11,285 max in 24
months
|
|
|
Inpatient
|
100% |
|
Outpatient
|
$20 copay
|
|
Retail Prescriptions
(Participating Pharmacies)
|
Generic: $15
copay
Brand Name: $30 copay |
|
Supply Limit per Copay |
30-day
supply
|
|
Mail Order Prescriptions
|
Generic: $15
copay
Brand Name: $30 copay |
|
Supply Limit per Copay |
30-day
supply
|
|
Vision Benefit - one
exam/yr |
$20 copay
See the self-funded NBN
Vision Plan Summary offered by the
Seattle
Public Schools to all eligible employees. |
|
Hearing/Audio Benefit |
$20 copay for exam once every 12 months;
No hardware benefit |
|
Notes |
*No benefits are payable for services outside of the
Group Health Managed Care Network unless it is a
medical emergency. Also, referrals are generally
required from your Primary Care Provider (PCP) for
care outside your PCP. |
