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HealthPays™ HSA Premiums | HealthPays™ HSA Benefits 

HealthPays HSA 2750/5500 Catastrophic Benefits	Alliant Plus In-network	Alliant Plus Out-of-network
Annual Deductible	$2,750 per Individual or $5,500 Family
Member Coinsurance	20%	40%
Out-of-Pocket Limit+	$5,100 per member or $10,200 per family
Benefits	After deductible, member pays
Office Visits Including mental health outpatient services.	20%	40%
Manipulative therapy Limit total visits PCY† to 10 combined for both in- and out-of-network.	20%	40%
Acupuncture	20%, up to 8 visits PCY	40%
Naturopathy	20%, up to 3 visits PCY	40%
Maternity care	Not covered	Not covered
Lab/X-ray Services	20%	40%
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. Maternity care not covered.	20%	40%
Devices, equipment & supplies (DME and prosthetics.)	Covered up to 50%
Prescription drugs	Not covered	Not covered
Emergency care	20%	40%
Vision Care	Not covered	Not covered
	Deductible does not apply
Preventive care visits  For children and adults, including physicals and immunizations, as established in GroupHealth’s preventive care schedule.	Covered in full	40% $300 individual/$600 family annual benefit maximum

+ Member coinsurance and annual deductible apply to out-of-pocket limit.
† PCY = per calendar year
‡ Western Washington counties: King, Kitsap, Pierce, Snohomish, Island, Thurston, Whatcom, Skagit, San Juan, Mason, Lewis, and Gray’s Harbor (ZIP codes: 98541, 98557, 98559, & 98568). Central/Eastern Washington counties: Kittitas, Yakima, Benton, Franklin, Walla Walla, Columbia, Whitman, and Spokane.

NOTE: This is a summary of benefits. The contents are not to be accepted or construed as a substitute for the provisions of the master policy or agreements. Other terms and conditions apply. All plans cover on-the-job-injury-related health care costs for partners, proprietors, or corporate officers who are not covered by a workers’ compensation act, subject to the plan’s cost shares and benefit limitations

Coverage provided by Group Health Cooperative