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HealthPays™ HSA Premiums | HealthPays™ HSA Benefits 

HealthPays HSA Benefits	Alliant Plus In-network	Alliant Plus Out-of-network
Annual Deductible	$2,750 per Individual or $5,100 Family
Member Coinsurance	10%	20%
Out-of-Pocket Limit+	$5,100 per member or $10,200 per family
Lifetime Maximum Benefits	$2,000,000	$2,000,000
Benefits	After deductible, member pays
Office Visits Including mental health outpatient services.	10%	20%
Manipulative therapy Limit total visits PCY† to 10 combined for both in- and out-of-network.	10%, up to 10 visits PCY †	20%, up to 10 visits PCY
Acupuncture	10%, up to 8 visits PCY	20%
Naturopathy	10%, up to 3 visits PCY	20%
Maternity care	Not covered	Not covered
Lab/X-ray Services	10%	20%
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.	10%	20%
Devices, equipment & supplies (DME and prosthetics.)	DME—50% up to $5,000 in charges ($2,500 max. benefit PCY); Prosthetics—50% up to $40,000 in charges ($20,000 max. benefit PCY)
Prescription drugs	Not covered	Not covered
Emergency care	10%	20%
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.	10%	20% $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. Lifetime benefit maximum of $2 million applies to all plans. 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 Options, Inc.