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Benefits |
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Group Health Network |
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Annual Deductible |
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$750 per member or $2,250 per family
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 |
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Memeber Coinsurance |
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20% |
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Out-Of-Pocket Limit*
(Deductible does not apply.)
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$4,000 per member or $12,000 per family
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Benefits |
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After Deductible,
Member Pays |
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First 4 visits: You pay only your copayment for your primary or speciality care visits. Your deductible and coinsurance do not apply until after the 4th visit for services indicated by  |
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Office Visits
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$30 + 20% - Primary care
$50 + 20% - Speciality care |
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Preventive Care Visits
For children and adults; including physicals and immunizations, as established in Group Health's well-care schedule.
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Covered in full, deductible waived
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Manipulative Therapy
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$30/visit + 20%, up to 10 visits PCY** |
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Acupuncture
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$30/visit + 20%, up to 8 visits PCY |
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| Naturopathy |
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$30/visit + 20%, up to 3 visits PCY |
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Maternity Care
Outpatient non-routine prenatal and postpartum visits. Copay waived for routine care.
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$30/visit + 20%
Delivery & associated hospital care: $500 per day to 5 days/admit + 20% |
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Lab/X-Ray Services
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Deductible waived on first $400 PCY, then deductible and 20% apply. |
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Hospital Visits - Inpatient
Hospital room and board; inpatient surgery; anesthesia, intensive and coronary care; laboratory tests; radiology services; drugs while in hospital. Includes mental health inpatient treatment.
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$500 per day to 5 days/admit + 20% |
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Devices, Equipment & Supplies
(DME and prosthetics)
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DME — 50% up to $5,000 in charges ($2,500 max. benefit PCY); Prosthetics — 50% up to $40,000 in charges ($20,000 max. benefit PCY) |
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Prescription Drugs - Outpatient
Drugs and medicines that require prescription, including self-administered injectables, contraceptive drugs, devices, and supplies.
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$15 copay generic/30% brand-name
$3,000 annual benefit maximum
Not subject to deductible
Mail order: $5 discount for 30-day supply |
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Emergency Care
Group Health or Group Health-designated facilities:
Non-Group Health or non-Group Health-designated facilities worldwide, including urgent care facilities.
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$100 + 20%
$100 + 20% |
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Vision Care
$200 hardware benefit per 12 month period. Hardware not subject to deductible or coinsurance.
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$30 + 20% for routine eye exam |
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