X-ray and Lab Coverage
Complex Outpatient Imaging
Subject to Deductible
(MRI, CAT, PET, etc)
On the Job Coverage
% of clients choose
Eligible for HSA Account
Any Doctor or Hospital
You pay 20% after deductible
$300 max per person
Discount Plan at a
Group Health Pharmacy
For subscriber only
High Deductible with Office Visits
same as office visit,
You pay 25%, covered
$15 co-pay generic drugs, brand name drugs are not covered
for formulary drugs
For subscriber/spouse
when exempt from L&I
Includes coverage for Rx, Maternity, Vision and Office Visits
Exam and screenings
You pay 30% after
then 30% or 50% for
Brand name drugs
Per calendar year (PCY)
Exam with $30 co-pay
You pay 20% after
deductible or $30 co-pay
at Group Health
100% coverage up to
$500 Rx deductible for
Preferred brand, then 50%
covered to $2,500 PCY
(3rd tier brand not covered)
You pay 20% for Exam and hardware
$150 max per year
*additional benefits are covered at the co-insurance percentage after the deductible as been met
Please refer to summaries under detailed info for more complete information and to your contract upon enrollment for exact language of benefits and limitations.
The above summary is not a contract. Waiting periods for pre-existing conditions may apply.
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Age of Male Tobacco user? Age of Female Tobacco user? # of Children
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Online Application Instructions
Our Simplified Plan Summary
Insurance company Plan Summary
All Above Documents
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