Covered Expenses
Only medically necessary services, supplies and prescription drugs are covered.
Alternative Care
Covered services, when medically necessary, include:
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acupuncture (certain limits apply);
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home births for low-risk pregnancies (see any Group Health network midwife for covered prenatal and home birth services);
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massage therapy, as part of a formal rehabilitation program; and
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naturopathy (certain limits apply).
You can self-refer for acupuncture and naturopathy care, but referral by a PCP is required for home births and massage therapy.
Ambulance Services
Group Health covers ambulance services if:
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ordered or approved by a network provider;
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other transportation would endanger your health; and
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the transportation isn't for personal or convenience reasons.
Chemical Dependency Treatment
Chemical dependency is a physiological and/or psychological dependency on a controlled substance and/or alcohol which substantially impairs or endangers your health, or substantially disrupts your ability to function socially or to work.
Your PCP can arrange chemical dependency treatment, or for outpatient care, you may call Group Health Behavioral Health. For additional counseling and referral services, you may also call the Making Life Easier Program. (See Contact Information.)
Treatment may include the following inpatient or outpatient services:
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covered prescription drugs and medicines;
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diagnostic evaluation and education; and
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organized individual and group counseling.
Detoxification services are covered as any other medical condition and aren't subject to the chemical dependency limit. (For plan benefits, see " Group Health Benefits at a Glance.")
Chiropractic Care and Manipulative Therapy
Group Health covers medically necessary manipulative therapy of the spine and extremities. You don't need a referral from your PCP before you see a network chiropractor or osteopath—you may self-refer. Associated X-rays are covered when provided at a Group Health radiology facility. (For plan benefits, see " Group Health Benefits at a Glance.")
Diabetes Care Training and Supplies
Diabetes care training includes diet counseling, enrollment in diabetes registry and a wide variety of education materials.
Group Health covers the following supplies under either the prescription drug or durable medical equipment benefit:
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blood glucose monitoring reagents;
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diabetic monitoring equipment;
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external insulin pumps;
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insulin syringes;
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lancets; and
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urine testing reagents.
Durable Medical Equipment, Devices and Supplies
Group Health covers durable medical equipment if it:
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is designed for prolonged use;
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has a specific therapeutic purpose in treating an illness or injury;
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is prescribed by your Group Health physician and is part of the Group Health formulary, and
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is primarily and customarily used only for medical purposes.
Covered items include:
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artificial limbs or eyes (including implant lenses prescribed by a network provider and required as the result of cataract surgery or to replace a missing portion of the eye);
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diabetic equipment for home testing and insulin administration (excluding batteries) not covered under the prescription benefit (For details about prescription drug coverage, see "Prescription Drugs");
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external breast prosthesis and bra following mastectomy; 1 external breast prosthesis per diseased breast every 2 years and 2 post-mastectomy bras every 6 months (up to 4 in any consecutive 12 months);
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non-prosthetic orthopedic appliances attached to an impaired body segment. These appliances must protect the body segment or aid in restoring or improving its function;
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orthopedic appliances;
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ostomy supplies;
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oxygen and equipment for its administration;
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prosthetic devices;
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purchase of nasal CPAP devices and initial purchase of associated supplies (Group Health provides a referral; you must rent the device for two months before it may be purchased; you pay 20% of the rental and purchase cost if you are covered by Group Health Gold or 50% if you are enrolled in Silver or Bronze);
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rental or purchase (decided by Group Health) of durable medical equipment such as wheelchairs, hospital beds and respiratory equipment (combined rental fees may not exceed full purchase price); and
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splints, crutches, trusses or braces.
Emergency Room Care
Emergency room care is for medical conditions that threaten loss of life or limb or may cause serious harm to the patient's health if not treated immediately. You don't need a referral from your PCP before you receive emergency room care. Examples of conditions that might require emergency room care include:
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an apparent heart attack (chest pain, sweating, nausea);
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convulsions;
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major burns;
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severe breathing problems;
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unconsciousness or confusion, especially after a head injury; and
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uncontrollable bleeding.
If you need emergency room care, follow these steps:
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Call 911 or go to the nearest hospital emergency room immediately. In cases when you can choose an emergency location, go to the Eastside Hospital in Redmond —this will allow Group Health to coordinate your care efficiently and perhaps reduce your expenses.
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When you arrive, show your Group Health ID card.
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If you're admitted to an out-of-network facility, you must call 1-888-457-9516 within 24 hours; otherwise, you may be responsible for all costs incurred before you call. If you're unable to call, ask a friend, relative or hospital staff person to call for you. Group Health's phone number is printed on the back of your ID card.
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If you're admitted to a health care facility, you must notify Group Health within 24 hours. You may be required to transfer your care to a network provider and/or Group Health facility. If you refuse to transfer to a Group Health facility, all further costs incurred during the hospitalization will be your responsibility.
In general, follow-up care that is the direct result of the emergency must be received through Group Health. Non-emergency use of an emergency facility isn't covered.
Family Planning
Group Health covers the following family planning expenses:
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family planning counseling;
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services to insert intrauterine birth control devices (IUDs);
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sterilization procedures; and
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voluntary termination of pregnancy (abortion).
Birth control drugs are covered under the prescription drug benefit. (For details about prescription drug coverage, see " Prescription Drugs.")
Growth Hormones
Group Health covers growth hormones. You or your family member won't be eligible for any growth hormone benefits until the first day of the 13th month of continuous coverage under Group Health, whether or not the growth disorder existed before coverage began. (For plan benefits, see " Group Health Benefits at a Glance.")
Hearing Aids
Home Health Care
Group Health covers home health care if the patient is unable to leave home due to health problems or illness and the care is necessary because of a medically predictable, recurring need. Unwillingness to travel and/or arrange for transportation doesn't constitute an inability to leave home. If you have an approved plan of treatment and referral from a network provider, covered expenses include:
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medical social worker and limited home health aide services;
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nursing care;
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occupational therapy;
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physical therapy;
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respiratory therapy; and
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restorative speech therapy.
Hospice Care
Hospice care is a coordinated program of supportive care for a dying person provided by a team of professionals and volunteers. The team may include a physician, nurse, medical social worker; physical, speech, occupational or respiratory therapist; or home health aide under the supervision of a registered nurse.
Group Health covers hospice services if:
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a network provider determines that the patient's illness is terminal with a life expectancy of six months or less, and it can be appropriately managed in the home or hospice facility;
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the patient has chosen comforting and supportive services rather than treatment aimed at curing the terminal illness;
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the patient has elected in writing to receive hospice care through the Group Health-approved hospice program; and
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the patient has a primary care person who will be responsible for the patient's home care.
One period of continuous home care hospice service is covered. A continuous home care period is skilled nursing care provided in the home 24 hours a day during a period of crisis to maintain a terminally ill patient at home. A network provider must determine that the patient would otherwise require hospitalization.
Continuous respite care may be covered for up to five days per occurrence of hospice care. Respite care must be given in the most appropriate setting as determined by your network provider.
Other covered hospice services may include:
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counseling services for the patient and the primary caregiver(s);
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drugs and biologicals used primarily for the relief of pain and symptom management;
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medical appliances and supplies primarily for the relief of pain and symptom management; and
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bereavement counseling services for the family.
Hospital Care
Group health covers the following hospital care expenses:
Inpatient Care Alternatives
Lab, X-ray and Other Diagnostic Testing
Group Health covers diagnostic X-ray, nuclear medicine, ultrasound and laboratory services. (For plan benefits, see " Group Health Benefits at a Glance." For more information on routine diagnostic testing such as a mammogram, see " Preventive Care.")
Maternity Care
Group Health covers maternity care if provided by a:
Covered maternity care includes:
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complications of pregnancy or delivery;
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hospitalization and delivery, including home births and certain birthing centers for low-risk pregnancies;
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postpartum care;
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pregnancy care;
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related genetic counseling when medically necessary for prenatal diagnosis of an unborn child's congenital disorders; and
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screening and diagnostic procedures during pregnancy.
HOSPITAL STAYS AND FEDERAL LAW
Group medical plans and health insurers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section. However, federal law generally doesn't prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother and/or newborn earlier than 48 hours or 96 hours, as applicable. In any case, plans and insurers may not require a provider to obtain authorization for prescribing a stay that doesn't exceed 48 hours or 96 hours, as applicable.
You don't need to preauthorize the length of stay unless it exceeds the 48- or 96-hour rule.
Mental Health Care
Group Health covers inpatient and outpatient mental health services. These services, which place priority on restoring social and occupational functioning, include:
Your PCP can arrange for mental health services, or you may contact Group Health Behavioral Health directly. Counseling and referral services are also available through the Making Life Easier Program. (See Contact Information.) Group Health also covers services authorized by Group Health's medical director which can be expected to improve or stabilize a condition.
Neurodevelopmental Therapy
Some neurodevelopmental therapy-related services aren't covered. (For details, see " Expenses Not Covered.")
Group Health covers neurodevelopmental therapy for covered family members age six and younger, including:
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hospital care;
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maintenance of the patient when his or her condition would significantly worsen without such services;
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occupational, speech and physical therapy (if ordered and periodically reviewed by a physician);
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physician services; and
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services to restore and improve function.
Newborn Care
Group Health covers newborns under the mother's health plan for the first three weeks, as required by Washington State law. (For plan benefits, see " Group Health Benefits at a Glance.") To continue the newborn's coverage after three weeks, the newborn must be eligible and enrolled within 60 days of birth. (For information about enrolling newborns, see " Adding Eligible Dependents.")
Phenylketonuria (PKU) Formula
Physician and Other Medical/Surgical Services
Group Health covers other medical and surgical services, including:
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bariatric surgery and related hospitalizations when Group Health criteria are met;
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blood and blood derivatives and their administration;
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circumcision;
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general anesthesia services and related facility charges for dental procedures for patients who are under age 7, who are physically or developmentally disabled or who have a medical condition where the patient's health would be put at risk if the dental procedure were performed in the dentist's office. These services must be authorized in advance by Group Health and performed at a Group Health hospital or ambulatory surgery facility;
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non-experimental implants limited to cardiac devices, artificial joints and intraocular lenses;
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outpatient diagnostic radiology and lab services;
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outpatient radiation therapy and chemotherapy;
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outpatient surgical services;
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outpatient total parenteral nutrition therapy;
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procedures performed by a network provider or oral surgeon (reduction of a fracture or dislocation of the jaw or facial bones; excision of tumors or cysts of the jaw, cheeks, lips, tongue, gums, roof or floor of the mouth; incision of salivary glands and ducts; accidental injury to teeth not covered);
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services of a podiatrist;
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sterilization procedures; and
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treatment of growth disorders by growth hormones subject to certain limits. (See "Growth Hormones" for details.)
Prescription Drugs
Benefits are provided for legend drugs and other covered items, including insulin, injectables and contraceptive drugs and devices when you use a network pharmacy or mail-order service, including off-label use of FDA-approved drugs. To be covered, prescriptions must be:
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prescribed by a network provider for covered conditions; and
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filled through a network pharmacy or the mail-order service.
To fill your prescription through a network pharmacy, show the pharmacist your Group Health ID card. For mail-order prescriptions, your provider will first prescribe a 30-day "trial" supply, which you'll fill through a network pharmacy. If the trial supply is effective, you can order a 90-day supply by contacting the mail-order service through the Group Health Web site. (See Contact Information.) Your prescription will be mailed to your home.
If you need a refill, check the label on the prescription container; some may be refilled without consulting your physician. The number of refills is indicated on the label. If you need your physician's approval to reorder your medication, call your pharmacy or the mail-order service at least two weeks before you run out of medication. The pharmacy/mail-order service will need time to order your medicine and contact your physician for approval. (For plan benefits, see " Group Health Benefits at a Glance.")
Generic drugs are used whenever available. Brand-name drugs are used if there is no generic equivalent. You may choose to buy specific brand-name drugs by paying the higher copay if they're available at the network pharmacy.
Preventive Care
Group Health covers the following preventive care services:
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most immunizations and vaccinations for adults and children (except immunizations for travel);
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routine hearing exams (once in 12 consecutive months);
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routine mammograms (age and risk factor determine frequency);
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routine physicals for adults and children (age and risk factor determine frequency); and
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routine vision exams (once in 12 consecutive months).
Preventive care is provided according to the following schedule. The schedule is a guideline; benefits may be available for more frequent care depending on the situation. Before scheduling a routine physical, confirm with Group Health that your physical will be covered.
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Routine newborn care, plus 7 well-baby office exams
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4 well-child exams, with 1 exam in each of these age groups: 2, 3, 4, 5
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4 well-child exams, with 1 exam in each of these age groups: 6, 7–8, 9–10, 11–12
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2 well-teen exams, with 1 exam for ages 13–15 and 1 exam for ages 15–17
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1 well-adult exam every 4-5 years
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1 well-adult exam every 4-5 years
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1 well-adult exam every 2 years
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Radiation Therapy, Chemotherapy and Respiratory Therapy
Group Health covers radiation therapy, high-dose chemotherapy and stem cell support, and respiratory therapy services. (For plan benefits, see " Group Health Benefits at a Glance.")
Reconstructive Services
Group Health covers reconstructive services to correct a congenital disease/anomaly or a medical condition (following an injury or incidental to surgery) that had a major effect on the patient's appearance (the reconstructive services must, in the opinion of a network provider, be reasonably expected to correct the condition).
Group Health covers the following services if the patient is receiving benefits for a mastectomy and elects breast reconstruction in connection with the mastectomy, as determined in consultation with the attending physician:
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prosthesis and treatment of physical complications of all stages of mastectomy, including lymphedemas;
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reconstruction of the breast on which the mastectomy has been performed; and
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surgery and reconstruction of the healthy breast to produce a symmetrical appearance.
These reconstructive benefits are subject to the same annual deductible and coinsurance provisions as other medical and surgical benefits. (For plan benefits, see " Group Health Benefits at a Glance.")
Rehabilitative Services
Group Health covers inpatient and outpatient rehabilitative services only for physical, occupational and speech therapy to restore function after illness, injury or surgery. Rehabilitative services are covered only when Group Health determines that they're expected to result in significant, measurable improvement within 60 days. (For plan benefits, see " Group Health Benefits at a Glance.")
Skilled Nursing Facility
Group Health covers skilled nursing facility services when the patient is referred by a network provider. (For plan benefits, see " Group Health Benefits at a Glance.")
Smoking Cessation
You don't need a PCP referral to a network provider to take advantage of these smoking cessation benefits.
Group Health covers the following, without a lifetime limit:
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one course of nicotine replacement therapy a year if you're actively participating in the Group Health-designated tobacco cessation program, Free & Clear® Quit for Life™ Program (For more information, visit www.ghc.org/products/freeclr.jhtml);
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educational materials; and
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participation in one program a year from a network provider.
For approved smoking cessation products, such as gum, patches or prescription medication, you need to purchase the product from a Group Health pharmacy or a contracted community pharmacy and pay the prescription drug copay. (For plan benefits, see " Group Health Benefits at a Glance.")
Temporomandibular Joint (TMJ) Disorders
Group Health covers:
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medical and surgical services and related hospitalizations to treat TMJ disorders when medically necessary;
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orthognathic (jaw) surgery;
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radiology services; and
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TMJ specialist services, including the fitting and adjustment of splints.
Additional benefits are available through the Dental Plan.
Transplants
Group Health covers professional and facility fees for inpatient accommodation, diagnostic tests and exams, surgery and follow-up care, as well as certain donor expenses, related to transplants.
You and your covered dependents aren't eligible for organ transplant benefits until the first day of the 13th month of continuous coverage under Group Health, regardless of whether the condition necessitating the transplant existed before coverage began (unless the patient was continuously covered under this plan since birth or he/she requires a transplant as the result of a condition that had a sudden unexpected onset after the patient's effective date of coverage).
The following transplants are covered:
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bone marrow;
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cornea;
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heart;
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heart-lung;
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intestinal/multi-visceral;
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kidney;
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liver;
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lung (single or double);
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pancreas;
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kidney; and
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stem cell support (obtained from allogeneic or autologous peripheral blood or morrow) with associated high dose chemotherapy.
Transplant services must be received at a facility designated by Group Health and are limited to:
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evaluation testing to determine recipient candidacy;
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follow-up services for specialty visits, re-hospitalization and maintenance medication; and
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transplantation (limited to costs for surgery and hospitalization related to the transplant, as well as medications).
Group Health covers the following donor expenses for a covered organ recipient:
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excision fees;
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matching tests;
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procurement center fees; and
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travel costs for a surgical team.
Urgent Care
Group Health covers treatment for conditions that aren't considered a medical emergency but may need immediate medical attention. Examples of urgent conditions include:
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ear infections;
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high fevers; and
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minor burns.
If you need urgent care during office hours, call your PCP's office for assistance. After office hours, call Group Health's Consulting Nurse Service at 1-800-297-6877. Depending on your situation, the consulting nurse may provide instructions over the phone for self-care, instruct you to make an appointment with your PCP for the next day or advise you to go to the nearest urgent care or emergency room.
Vision Exams
Group Health covers routine vision exams only. (For plan benefits, see " Group Health Benefits at a Glance.") The Vision Plan provides benefits for eye exams and for prescription lenses and frames.
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