Compare your plan options

(1)

FEDERAL EMPLOYEES

RATES & BENEFITS

2016

Compare your

plan options

(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 e-mail 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.}

(3)

TYPE OF ENROLLMENT

Non-Postal Premium Postal Premium

Biweekly

Your Share Your ShareMonthly Biweekly Category 1 Your Share Biweekly Category 2 Your Share

HIGH DEDUCTIBLE PLAN Self Only Code PT1 $54.67 $118.46 $45.38 $54.67

HIGH DEDUCTIBLE PLAN Self Plus One Code PT3 $109.35 $236.92 $90.76 $109.35

HIGH DEDUCTIBLE PLAN Self and Family Code PT2 $147.62 $319.85 $122.53 $147.62

STANDARD OPTION Self Only Code 544 $58.52 $126.79 $48.57 $58.52

STANDARD OPTION Self Plus One Code 546 $117.04 $253.58 $97.14 $117.04

STANDARD OPTION Self and Family Code 545 $158.00 $342.34 $131.14 $158.00

HIGH OPTION Self Only Code 541 $113.76 $246.48 $101.90 $113.76

HIGH OPTION Self Plus One Code 543 $193.23 $418.66 $167.62 $193.23

HIGH OPTION Self and Family Code 542 $394.74 $855.27 $367.60 $394.74

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 1-888-901-4636.

(4)

COVERAGE

Annual deductible

Individual / Family $1,500 / $3,000 Deductible applies to all services except as noted

Annual out-of-pocket limit

Individual / Family $3,500 / $7,000

Annual medical fund contribution

Individual / Family $750 / $1,500

BENEFITS

Office visit (primary care / specialty care) 20% coinsurance

Preventive care visit Covered in full, not subject to deductible

Chiropractic/manipulative therapy services

Self-refer to 20 visits per member PCY* 20% coinsurance

Naturopathy

Self-refer to 3 visits per medical diagnosis PCY* 20% coinsurance

Acupuncture

Self-refer to 8 visits per medical diagnosis PCY*

For substance abuse, unlimited visits 20% coinsurance

Mental health Inpatient: 20% coinsurance per admit _{Outpatient: 20% coinsurance} Rehabilitation – outpatient

60 visits per medical diagnosis PCY* 20% coinsurance

Lab/X-ray 20% coinsurance

Hospital Inpatient: 20% coinsurance per admit _{Outpatient surgery: 20% coinsurance} Urgent care 20% coinsurance

Ambulance 20% coinsurance

Emergency care 20% coinsurance

PRESCRIPTION DRUGS

Tier 1: Formulary generic

1-month supply

90-day mail order supply $10 copay$20 copay

Tier 2: Formulary brand

1-month supply

90-day mail order supply 20% coinsurance up to $100 20% coinsurance up to $200

Tier 3: Non-formulary

1-month supply

90-day mail order supply 40% coinsurance up to $250 40% coinsurance up to $500

Tier 4: Formulary specialty

1-month supply 25% coinsurance up to $200

Tier 5: Non-formulary specialty

DENTAL

Dental (preventive)

$50 individual / $150 family deductible

$750 maximum benefit Not covered

(5)

COVERAGE

Individual / Family $350 / $700Deductible applies to all services except as noted

Individual / Family N/A

BENEFITS

Office visit (primary care / specialty care) $25 copay primary / $35 copay specialty

Preventive care visit Covered in full, not subject to deductible

Self-refer to 20 visits per member PCY* $25 copay primary / $35 copay specialty

Naturopathy

Self-refer to 3 visits per medical diagnosis PCY* $25 copay primary / $35 copay specialty

Acupuncture

For substance abuse, unlimited visits $25 copay primary / $35 copay specialty

Mental health Inpatient: $500 copay per admit_{Outpatient: $25 copay primary / $35 copay specialty} Rehabilitation – outpatient

60 visits per medical diagnosis PCY* $25 copay primary / $35 copay specialty

Lab/X-ray Covered in full, after deductible

Hospital Inpatient: $500 copay per admit_{Outpatient surgery: $100 copay}

Urgent care $25 copay

Ambulance 20% coinsurance, not subject to deductible

Emergency care $150 per visit

1-month supply

DENTAL

$50 individual / $150 family deductible

$750 maximum benefit Not covered

(6)

COVERAGE

Individual / Family None

Individual / Family N/A

BENEFITS

Office visit (primary care / specialty care) $25 copay primary / $25 specialty

Preventive care visit Covered in full

Self-refer to 20 visits per member PCY* $25 copay

Naturopathy

Self-refer to 3 visits per medical diagnosis PCY* $25 copay

Acupuncture

For substance abuse, unlimited visits $25 copay

Mental health Inpatient: $350 copay per admit_{Outpatient: $25 copay} Rehabilitation – outpatient

60 visits per medical diagnosis PCY* $25 copay

Lab/X-ray Covered in full

Hospital Inpatient: $350 copay per admit_{Outpatient surgery: $75 copay}

Urgent care $25 copay

Ambulance 20% coinsurance

Emergency care $100 per visit

1-month supply

DENTAL

$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 1-888-901-4636.

How do I find a provider when I’m traveling?

You can always call Group Health Customer Service toll-free at 1-888-901-4636 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 1-888-901-4636 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 206-901-4444 or toll-free at 1-800-245-7979. 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?

(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 $25 copay 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 well-care 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).