Group Health Benefits at a Glance


Covered Expenses	Group Health Gold		Group Health Silver	Group Health Bronze
Alternative care (including medically necessary acupuncture, massage therapy and naturopathy)	Self-referrals to a network provider: $20 copay/visit Up to 8 visits/medical diagnosis/calendar year for acupuncture Up to 3 visits/medical diagnosis/calendar year for naturopathy; except for chiropractic services All other alternative care may require PCP referral.		Self-referrals to a network provider: $35 copay/visit Up to 8 visits/medical diagnosis/calendar year for acupuncture Up to 3 visits/medical diagnosis/calendar year for naturopathy; except for chiropractic services All other alternative care may require PCP referral.	Self-referrals to a network provider: $50 copay/visit Up to 8 visits/medical diagnosis/calendar year for acupuncture Up to 3 visits/medical diagnosis/calendar year for naturopathy; except for chiropractic services All other alternative care may require PCP referral.
Ambulance services	80% (except hospital-to-hospital ground transfers, which are covered at 100% when initiated by Group Health)
Chemical dependency treatment (requires preauthorization)	For inpatient care: 100% after $200 copay/admission For outpatient care: 100% after $20 copay/visit Up to $13,500 in 24 consecutive months (maximum subject to annual adjustment)		For inpatient care: 100% after $400 copay/admission For outpatient care: 100% after $35 copay/visit Up to $13,500 in 24 consecutive months (maximum subject to annual adjustment)	For inpatient care: 100% after $600 copay/admission For outpatient care: 100% after $50 copay/visit Up to $13,500 in 24 consecutive months (maximum subject to annual adjustment)
Chiropractic care and manipulative therapy (like all services, must be medically necessary)	100% after $20 copay/visit		100% after $35 copay/visit	100% after $50 copay/visit
Diabetes care training	100% after $20 copay/visit		100% after $35 copay/visit	100% after $50 copay/visit
Diabetes supplies (insulin, needles, syringes, lancets, etc.)	Covered under prescription drugs		Covered under prescription drugs	Covered under prescription drugs
Durable medical equipment, prosthetics and orthopedic appliances	80% when preauthorized		50% when preauthorized	50% when preauthorized
Emergency room care	Network: 100% after $100 copay/visit ($100 copay is waived, but $200 copay/admission for hospital care applies if admitted) Out-of-network: 100% of reasonable and customary expenses after $150 copay/visit ($150 copay is waived but $200 copay/admission for hospital care applies if admitted) Non-emergency care is not covered.		Network: 100% after $100 copay/visit ($100 copay is waived, but $400 copay/admission for hospital care applies if admitted) Out-of-network: 100% of reasonable and customary expenses after $150 copay/visit ($150 copay is waived, but $400 copay/ admission for hospital care applies if admitted) Non-emergency care is not covered.	Network: 100% after $100 copay/visit ($100 copay is waived, but $600 copay/admission for hospital care applies if admitted) Out-of-network: 100% of reasonable and customary expenses after $150 copay/visit ($150 copay is waived, but $600 copay/ admission for hospital care applies if admitted) Non-emergency care is not covered.
Family planning	100% after $20 copay/visit Infertility treatment is not covered.		100% after $35 copay/visit Infertility treatment is not covered.	100% after $50 copay/visit Infertility treatment is not covered.
Growth hormones	Covered under prescription drugs if medical coverage has been continuous for more than 12 months under this plan whether or not the growth disorder existed before plan coverage
Hearing aids	100%, up to $300/ear in 36 months
Home health care	100%
Hospice care	100% when preauthorized Certain limits apply; call plan for details.
Hospital care	100% after $200 copay/admission	100% after $400 copay/admission		100% after $600 copay/admission
Inpatient care alternatives	100% when preauthorized
Lab, X-ray and other diagnostic testing	100%
Maternity care	For delivery and related hospital care: 100% after $200 copay/admission For prenatal and postpartum care: 100% after $20 copay/visit	For delivery and related hospital care: 100% after $400 copay/admission For prenatal and postpartum care: 100% after $35 copay/visit		For delivery and related hospital care: 100% after $800 copay/admission For prenatal and postpartum care: 100% after $50 copay/visit
Mental health care (when deemed appropriate, 2 unused outpatient visits may be traded for 1 inpatient day, or vice versa; requires preauthorization)	For inpatient care: 100% after $200 copay per admission, up to 12 days/year For outpatient care: 100% after $20 copay/individual, family, couple or group session, up to 20 visits/year	For inpatient care: 100% after $400 copay per admission, up to 12 days/year For outpatient care: 100% after $35 copay/individual, family, couple or group session, up to 20 visits/year		For inpatient care: 100% after $600 copay per visit, up to 12 days/year For outpatient care: 100% after $50 copay/individual, family, couple or group session, up to 20 visits/year
Neurodevelopmental therapy for dependents age 6 and under	For inpatient care: 100% after $200 copay/admission, up to 60 days/year (combined with rehabilitative services) For outpatient care: 100% after $20 copay/visit, up to 60 visits/year (combined with rehabilitative services)	For inpatient care: 100% after $400 copay/admission, up to 60 days/year (combined with rehabilitative services) For outpatient care: 100% after $35 copay/visit, up to 60 visits/year (combined with rehabilitative services)		For inpatient care: 100% after $600 copay/admission, up to 60 days/year (combined with rehabilitative services) For outpatient care: 100% after $50 copay/visit, up to 60 visits/year (combined with rehabilitative services)
Out-of-area coverage—for example, while traveling or for your children away at school	Reciprocal benefits are available through Kaiser Permanente and affiliated HMOs; otherwise, only emergency services are covered out of area.
Phenylketonuria (PKU) formula	100%
Physician and other medical/surgical services	For inpatient care: 100% For outpatient care: 100% after $20 copay/office visit	For inpatient care: 100% For outpatient care: 100% after $35 copay/office visit		For inpatient care: 100% For outpatient care: 100% after $50 copay/office visit
Prescription drugs—Up to a 30-day supply through network pharmacies	Generic: 100% after $10 copay Preferred brand: 100% after $20 copay Non-preferred brand: 100% after $30 copay Growth hormones: 100% There's no reimbursement for prescriptions filled at out-of-network or out-of-area pharmacies.
Prescription drug—Up to a 90-day supply through mail-order network only	Generic: 100% after $20 copay Preferred brand: 100% after $40 copay Non-preferred brand: 100% after $60 copay
Preventive care (well-child check-ups, immunizations, routine health and hearing exams. etc.)	100% after $20 copay/visit (according to well-child/adult preventive schedule)	100% after $35 copay/visit (according to well-child/adult preventive schedule)		100% after $50 copay/visit (according to well-child/adult preventive schedule)
Radiation therapy, chemotherapy and respiratory therapy	100% after $20 copay/visit	100% after $35 copay/visit		100% after $50 copay/visit
Reconstructive services (includes benefits for mastectomy-related services; reconstruction and surgery to achieve symmetry between the breasts, prostheses and complications resulting from mastectomy, including lymphedema) Call plan for more information.	100% depending on services provided; copays may apply (including $200 copay/admission if hospital care is required)	100% depending on services provided; copays may apply (including $400 copay/admission if hospital care required)		100% depending on services provided; copays may apply (including $600 copay/admission if hospital care required)
Rehabilitative services—Inpatient and outpatient	For inpatient care: 100% after $200 copay/admission, up to 60 days/calendar year (combined with neurodevelopmental therapy) For outpatient care: 100% after $20 copay/visit for outpatient services, up to 60 visits/calendar year (combined with neurodevelopmental therapy)	For inpatient care: 100% after $400 copay/admission, up to 60 days/calendar year (combined with neurodevelopmental therapy) For outpatient care: 100% after $35 copay/visit, up to 60 visits/calendar year (combined with neurodevelopmental therapy)		For inpatient care: 100% after $600 copay/admission, up to 60 days/calendar year (combined with neurodevelopmental therapy) For outpatient care: 100% after $50 copay/visit, up to 60 visits/calendar year (combined with neurodevelopmental therapy)
Skilled nursing facility	100% up to 60 days/calendar year at a Group Health-approved nursing facility
Smoking cessation	100% for one Group Health network provider program/calendar year One course of nicotine replacement/calendar year (prescription benefit copay applies) when prescribed by Group Health PCP if the member is actively participating in the Free and Clear Program No lifetime limit
Temporomandibular joint (TMJ) disorders	For inpatient care: 100% after $200 copay/admission For outpatient care: 100% after $20 copay/visit Up to $1,000/calendar year and a $5,000 lifetime maximum	For inpatient care: 100% after $400 copay/admission For outpatient care: 100% after $35 copay/visit Up to $1,000/calendar year and a $5,000 lifetime maximum		For inpatient care: 100% after $600 copay/admission For outpatient care: 100% after $50 copay/visit Up to $1,000/calendar year and a $5,000 lifetime maximum
Transplants (certain services only)	100% after applicable copays Medical coverage must have been continuous for more than 12 months under this plan before a transplant will be covered.
Urgent care (ear infections, high fevers, minor burns)	100% after $20 copay/visit	100% after $35 copay/visit		100% after $50 copay/visit
Vision exams	100% after $20 copay/visit, up to 1 exam/person in 12 consecutive months (Group Health covers exams only; your separate Vision Service Plan covers eye exams, prescription lenses and frames)	100% after $35 copay/visit, up to 1 exam/person in 12 consecutive months (Group Health covers exams only; your separate Vision Service Plan covers eye exams, prescription lenses and frames)		100% after $50 copay/visit, up to 1 exam/person in 12 consecutive months (Group Health covers exams only; your separate Vision Service Plan covers eye exams, prescription lenses and frames)