Compare your plan options

Transcription

1 FEDERAL EMPLOYEES RATES & BENEFITS 2016 Compare your plan options Choose the plan that fits you and your family

2 Why choose Group Health? There are lots of reasons to choose Group Health, and for Federal employees, there are even more. Our Core/Group Health network includes more than 10,000 providers and features top-ranked* Group Health Physicians at 25 Group Health Medical Centers locations. Online services let you your doctor, make appointments, look up benefits, and check lab results, whenever it s convenient for you.** If you need medical advice, our Consulting Nurse Service is available 24/7. As a member of the Federal Employees Health Benefits (FEHB) program, when you choose Group Health you ll also get: Out-of-area coverage, including urgent and emergency care anywhere in the world, care at Kaiser Permanente locations, and $2,000 per year for certain other services. Health and wellness programs, including preventive care reminders, fitness club discounts through GlobalFit, nutrition program discounts, and help for quitting smoking included in your plan at no extra charge. Vision hardware discounts on frames, lenses, contacts, and OSHA-approved safety goggles at Group Health Eye Care Optical Shops. $50 e-gift card, that can be used at Amazon, Starbucks, Nordstrom, and many other retailers when plan subscribers complete a member health assessment online. * Highest-ranked medical group, Washington Health Alliance, 2014 Community Checkup ** Services available when you receive care at Group Health Medical Centers. The brands listed are not sponsors of the rewards or otherwise affiliated with Group Health. The logos and other identifying marks attached are trademarks of and owned by each represented company and/or its affiliates. Please visit each company s website for additional terms and conditions.

3 Which plan is right for you? There are three FEHB plans available for 2016, so you can choose what fits your coverage needs and budget. Plans feature the Core/Group Health provider network. NEW! Group Health High Deductible Health Plan Lower premium, with HSA or HRA If you and your family are in good health and not expecting any large medical expenses in the next year, you may want to look at the High Deductible Health Plan. This plan has a lower premium and a higher deductible. Your coverage begins after you pay the deductible amount, except for preventive care, which is covered in full right from the start. The plan can be paired with a health savings account (HSA) or health reimbursement arrangement (HRA) through HealthEquity. Once you re signed up for the HSA or HRA option, Group Health will help your health care dollars go further by contributing to your medical fund. And you can set aside tax-free dollars in your HealthEquity savings account. Learn more about HSAs and HRAs at healthequity.com Group Health Standard Option Lower premium If you and your family are in good health and don t go to the doctor very often, you might be interested in the Standard Option plan. This plan has a lower premium and includes a deductible, which you ll need to pay before your coverage begins, except for preventive care and a few other services. Group Health High Option Lower out-of-pocket costs If you see your doctor regularly, the High Option plan may be right for you. You ll have predictable costs with just a copay for most care. It has a slightly higher premium, but has no deductible and more affordable out-of-pocket costs. And it includes preventive dental care through Delta Dental of Washington. If you have Group Health Medicare Advantage (HMO) with your Federal coverage, and you d like a summary of benefits, please visit ghc.org/fehb or contact Group Health Customer Service at TYPE OF ENROLLMENT Biweekly Your Share Non-Postal Premium Monthly Your Share Biweekly Category 1 Your Share Postal Premium Biweekly Category 2 Your Share HIGH DEDUCTIBLE PLAN Self Only Code PT1 $54.67 $ $45.38 $54.67 HIGH DEDUCTIBLE PLAN Self Plus One Code PT3 $ $ $90.76 $ HIGH DEDUCTIBLE PLAN Self and Family Code PT2 $ $ $ $ STANDARD OPTION Self Only Code 544 $58.52 $ $48.57 $58.52 STANDARD OPTION Self Plus One Code 546 $ $ $97.14 $ STANDARD OPTION Self and Family Code 545 $ $ $ $ HIGH OPTION Self Only Code 541 $ $ $ $ HIGH OPTION Self Plus One Code 543 $ $ $ $ HIGH OPTION Self and Family Code 542 $ $ $ $ See Details and definitions on the back for explanations of some of the terms used in this brochure.

4 High deductible health plan COVERAGE Annual deductible Annual out-of-pocket limit Annual medical fund contribution $1,500 / $3,000 Deductible applies to all services except as noted $3,500 / $7,000 $750 / $1,500 BENEFITS Office visit (primary care / specialty care) Preventive care visit Chiropractic/manipulative therapy services Self-refer to 20 visits per member PCY* Naturopathy Self-refer to 3 visits per medical diagnosis PCY* Acupuncture Self-refer to 8 visits per medical diagnosis PCY* For substance abuse, unlimited visits Mental health Rehabilitation outpatient 60 visits per medical diagnosis PCY* Lab/X-ray Hospital Urgent care Ambulance Emergency care Covered in full, not subject to deductible Inpatient: per admit Outpatient: Inpatient: per admit Outpatient surgery: PRESCRIPTION DRUGS Tier 1: Formulary generic Tier 2: Formulary brand Tier 3: Non-formulary Tier 4: Formulary specialty Tier 5: Non-formulary specialty $10 copay $20 copay up to $100 up to $200 40% coinsurance up to $250 40% coinsurance up to $500 25% coinsurance up to $200 50% coinsurance up to $500 DENTAL Dental (preventive) $50 individual / $150 family deductible $750 maximum benefit Not covered

5 Standard option COVERAGE Annual deductible Annual out-of-pocket limit Annual medical fund contribution $350 / $700 Deductible applies to all services except as noted $5,000 / $5,000 N/A BENEFITS Office visit (primary care / specialty care) Preventive care visit Chiropractic/manipulative therapy services Self-refer to 20 visits per member PCY* Naturopathy Self-refer to 3 visits per medical diagnosis PCY* Acupuncture Self-refer to 8 visits per medical diagnosis PCY* For substance abuse, unlimited visits Mental health Rehabilitation outpatient 60 visits per medical diagnosis PCY* Lab/X-ray Hospital Urgent care Ambulance Emergency care primary / $35 copay specialty Covered in full, not subject to deductible primary / $35 copay specialty primary / $35 copay specialty primary / $35 copay specialty Inpatient: $500 copay per admit Outpatient: primary / $35 copay specialty primary / $35 copay specialty Covered in full, after deductible Inpatient: $500 copay per admit Outpatient surgery: $100 copay, not subject to deductible $150 per visit PRESCRIPTION DRUGS Tier 1: Formulary generic Tier 2: Formulary brand Tier 3: Non-formulary Tier 4: Formulary specialty Tier 5: Non-formulary specialty $20 copay $40 copay $40 copay $80 copay $60 copay $120 copay 25% coinsurance up to $200 50% coinsurance up to $500 DENTAL Dental (preventive) $50 individual / $150 family deductible $750 maximum benefit Not covered

6 High option COVERAGE Annual deductible Annual out-of-pocket limit Annual medical fund contribution None $3,000 / $6,000 N/A BENEFITS Office visit (primary care / specialty care) Preventive care visit Chiropractic/manipulative therapy services Self-refer to 20 visits per member PCY* Naturopathy Self-refer to 3 visits per medical diagnosis PCY* Acupuncture Self-refer to 8 visits per medical diagnosis PCY* For substance abuse, unlimited visits Mental health Rehabilitation outpatient 60 visits per medical diagnosis PCY* Lab/X-ray Hospital Urgent care Ambulance Emergency care primary / $25 specialty Covered in full Inpatient: $350 copay per admit Outpatient: Covered in full Inpatient: $350 copay per admit Outpatient surgery: $75 copay $100 per visit PRESCRIPTION DRUGS Tier 1: Formulary generic Tier 2: Formulary brand Tier 3: Non-formulary Tier 4: Formulary specialty Tier 5: Non-formulary specialty $20 copay $40 copay $40 copay $80 copay $60 copay $120 copay 25% coinsurance up to $200 50% coinsurance up to $500 DENTAL Dental (preventive) $50 individual / $150 family deductible $750 maximum benefit Preventive care covered in full, after deductible Periodontal care PPO provider: Member pays 50% coinsurance, after deductible Non-PPO provider: Member pays 70% coinsurance after deductible

7 How to get care when you re not near a Group Health clinic Am I covered for non-emergency care when I m traveling and not near any network providers? When you re away from home, you get access to any Kaiser Permanente facility at your level of coverage, including routine care. If you are not near a Kaiser Permanente facility, Group Health FEHB members can also take advantage of a $2,000 per member per year travel benefit. The following services and items are excluded under this benefit, even though they may be included under your Federal coverage: Dental Pharmaceutical items such as drugs, diabetic supplies, allergy injection, and contraceptive devices Durable medical equipment (DME) Optical (routine refractions and optical hardware) Skilled nursing facility What do I do if I have an emergency and go to a non-affiliated hospital or medical center? If you receive care at a non-affiliated hospital or medical center, you may be required to pay in full at the time of service. But don t worry. When you get home, just mail us your completed claims form and medical receipts so we can reimburse you for any covered charges. You ll find the form on ghc.org. Search medical and prescription claim form. Or you can request one by calling Group Health Customer Service toll-free at How do I find a provider when I m traveling? You can always call Group Health Customer Service toll-free at for assistance. If you are outside of the Group Health service area and in a state where there is not a Kaiser Permanente facility, you can use your $2,000 travel benefit. Your travel benefit dollars will go further when you use our preferred regional and national networks: The First Choice Health network and the First Health Network. Find out more about these networks in our online Provider and Facility Directory at ghc.org. Dental providers are excluded under this benefit. What if my child is a student who needs care and is not near any network providers? Students registered full-time in an accredited college or university are eligible for covered services at any Kaiser Permanente facility. Call Group Health Customer Service toll-free at for a complete list of services. If your student is attending college in a state where there is not a Kaiser Permanente facility, they can take advantage of the $2,000 per member per calendar year travel benefit. How do I get a prescription? There are four ways to get the prescription you need. You can go to a pharmacy at any Group Health Medical Centers location. You can visit a Core/Group Health network pharmacy. They re listed on ghc.org under Provider and Facility Directory. You can order by phone at or toll-free at Or you can order a refill online at ghc.org and receive it in the mail, usually within three to five business days, with free delivery. How do I get a prescription in an emergency when I m traveling? Outpatient medications prescribed or dispensed as a part of an emergency or urgent situation will be covered up to a 30-day supply. You may be required to pay for the total cost of the prescription up front, but can submit a request form for reimbursement upon your return home. You ll find the form on ghc.org. Search medical and prescription claim form. You can also request one by calling us toll-free at

8 Details and definitions Coinsurance A percentage amount you pay for a covered service or prescription. For example, you might pay 20 percent of the cost of your office visit each time you see your doctor. Copayment, copay A fixed dollar amount you pay for a covered service or prescription. For example, you might pay a each time you see your doctor. Deductible What you ll pay each year before your coverage kicks in. For certain services, such as preventive care, the deductible does not apply. Health savings account (HSA) An HSA is a personal savings account that s used to pay for eligible medical expenses. The money you deposit into your account is not taxed, and you own and control that money, even if you change employers. Health reimbursement arrangement HRA An HRA is an account set up by an employer and used to pay for eligible medical expenses. The money deposited into the account is not taxed. Only the employer can contribute to an HRA and the employer controls the account. Hospital stays 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. Out-of-pocket limit The most you ll be required to pay for covered services in a calendar year. After you ve paid this amount, the health plan pays for all covered services for the remainder of the year. Deductible, coinsurance, and copays count toward limit. Outpatient surgery Surgery in an office, outpatient surgery center, or hospital setting that does not require an overnight stay. Prescription drugs Outpatient: Formulary drugs and medicines that require prescriptions, including self-administered inject ables, mental health drugs, and diabetic supplies. Preventive care services For children and adults. Includes wellness visits and immunizations, as established in Group Health s wellcare schedule, formulary contraceptive drugs including counseling, contraceptive devices, and female sterilization. Devices and supplies related to contraception are covered as preventive as required by federal law and covered in full. Also includes drugs and medicines such as aspirin, fluoride, and folic acid. Primary care What you pay for a visit may vary depending on whether a service is considered primary care or specialty care. Primary care copays and coinsurance apply to: Acupuncture Audiology Chemical Dependency/Substance Abuse Chiro practic Emergency Medicine (where ER copay doesn t apply) Enterostomal Therapy Family Planning Family Medicine Internal Medicine Massage Therapy Mental Health Midwifery Naturopathy Nutrition (covered as preventive when requirements are met) Obstetrics/Gynecology Occupational Medicine Occupational Therapy Optometry Osteopathy Pediatrics Physical Therapy Respiratory Therapy Speech Therapy Urgent Care Women s Health Care Specialty care What you pay for a visit may vary depending on whether a service is considered primary care or specialty care. Specialty care copays and coinsurance apply to: Allergy and Immunology Anesthesiology Cardiology (pediatric and cardiovascular disease) Critical Care Medicine Dentistry Dermatology Endocrinology Gastroenterology Genetics Hematology Hepatology Infectious Disease Neonatal-Perinatal Medicine Nephrology Neurology Oncology Ophthalmology Orthopedics Otolaryngology (ear, nose, and throat) Pathology Physiatry (physical medicine) Podiatry Pulmonary Medicine/Disease Radiology (nuclear medicine, radiation therapy) Rheumatology Sports Medicine General Surgery (all surgical specialties) Urology Tier, drug tier A classification used to identify what cost share you pay for a drug. More commonly used and less expensive drugs are in lower tiers (for example, tier 1 or tier 2). Specialty or higher-cost drugs are classified in higher tiers (for example, tier 5). Coverage provided by Group Health Cooperative. 15-LRG