Washwick
PLANS & BENEFITS

PLAN 16
PLAN 15
PLAN 87

PLAN 86

MONTHLY PREMIUM

Main difference between HIP & GHI Hospitals:

GHI includes Slone Kettering, HIP does not.

Click below for provider links:
Multiplan Doctors
GHI Hospitals
HIP Hospitals

Multi-plan Drs
GHI Hospitals:

$  251.49 Single
$  486.99 Employee & Spouse
$  429.53 Employee & Child
$  665.02 Family (3-6 people)
$1026.27 Family (6+ people)

Multi-plan Drs
HIP Hospitals:
$ 224.65 Single
$ 433.31 Employee & Spouse
$ 382.39 Employee & Child
$ 591.05 Family (3-6 people)

$ 911.12 Family (6+ people)

Multi-plan Drs
GHI Hospitals:

$ 222.83 Single
$ 429.67 Employee & Spouse
$ 379.20 Employee & Child
$ 586.03 Family (3-6 people)
$ 903.31 Family (6+ people)

Multi-plan Drs
HIP Hospitals:
$ 199.22 Single
$ 382.44 Employee & Spouse
$ 337.74 Employee & Child
$ 520.96 Family (3-6 people)
$ 802.02 Family (6+ people)

Multi-plan Drs
GHI Hospitals:

$ 170.37 Single
$ 324.73 Employee & Spouse
$ 287.07 Employee & Child
$ 441.43 Family (3-6 people)
$ 678.23 Family (6+ people)

Multi-plan Drs
HIP Hospitals:
$ 152.67 Single
$ 289.34 Employee & Spouse
$ 255.99 Employee & Child
$ 392.66 Family (3-6 people)
$ 602.31 Family (6+ people)

Multi-plan Drs
GHI Hospitals:

$ 107.45 Single
$ 198.90 Employee & Spouse
$ 176.85 Employee & Child
$ 268.03 Family (3-6 people)
$ 408.32 Family (6+ people)

Multi-plan Drs
HIP Hospitals:
$   96.84 Single
$ 177.68 Employee & Spouse
$ 157.96 Employee & Child
$ 238.80 Family (3-6 people)
$ 362.81 Family (6+ people)

DEDUCTIBLE

$1500 Single / $3000 Family;

$2500 Single / $5000 Family;
$5,000 single / $10,000
family

$10,000
single / $20,000 family

Calendar Year Max Benefit

$5,000,000
$5,000,000
$5,000,000

$5,000,000

Office/Specialist Visits

100% Covered After Deductible

(for routine exam, deductible waived up to $250)

100% Covered After Deductible

(for routine exam, deductible waived up to $250)

100% Covered After Deductible

(for routine exam, deductible waived up to $250)

100% Covered After Deductible

(for routine exam, deductible waived up to $250)

Mammography

1 baseline age 35-39;
1 screening per year age 40+;
Screening at any age w/ prior history or family history;

100% Covered After Deductible

1 baseline age 35-39;
1 screening per year age 40+;
Screening at any age w/ prior history or family history;

100% Covered After Deductible

1 baseline age 35-39;
1 screening per year age 40+;
Screening at any age w/ prior history or family history;

100% Covered After Deductible

1 baseline age 35-39;
1 screening per year age 40+;
Screening at any age w/ prior history or family history;

100% Covered After Deductible
Bone Mineral Density Test

100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible

100% Covered After Deductible

Colorectal Cancer Screening

1 screening per year age 50+
1 screening per year age 50+
1 screening per year age 50+
1 screening per year age 50+
Prostate Cancer Screening

Screening at any age w/ prior history;
1 screening per year age 40+ with family history;
1 screening per year age 50+;

100% Covered After Deductible

Screening at any age w/ prior history;
1 screening per year age 40+ with family history;
1 screening per year age 50+;

100% Covered After Deductible

Screening at any age w/ prior history;
1 screening per year age 40+ with family history;
1 screening per year age 50+;

100% Covered After Deductible

Screening at any age w/ prior history;
1 screening per year age 40+ with family history;
1 screening per year age 50+;

100% Covered After Deductible
Lab, X-Ray, Diagnostic tests
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
Rehab services (physical, occupational, speech therapies)
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
Spinal manipulation
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible

Allergy testing & treatment
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
Services of physician, surgeon, anesthesiologist, radiologist, pathologist
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
Rx Drug Card
After your deductible, 70%/30% Coinsurance.  Out of pocket max: $1000, then 100%
After your deductible, 70%/30% Coinsurance.  Out of pocket max: $1000, then 100%
After your deductible, 70%/30% Coinsurance.  Out of pocket max: $1000, then 100%
After your deductible, 70%/30% Coinsurance.  Out of pocket max: $1000, then 100%
Emergency Room
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
Local Ambulance
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
Other Transportation

Up to $2500 for any one hospital confinement, and must be medically necessary;

100% Covered After Deductible

Up to $2500 for any one hospital confinement, and must be medically necessary;

100% Covered After Deductible

Up to $2500 for any one hospital confinement, and must be medically necessary;

100% Covered After Deductible

Up to $2500 for any one hospital confinement, and must be medically necessary;

100% Covered After Deductible

Hospital

***Precertification is required***
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible

Outpatient Surgery

***Precertification is required***
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible

Private Duty Nurse

***Precertification is required***
Up to $125 per day, 100% Covered After Deductible
Up to $125 per day, 100% Covered After Deductible
Up to $125 per day, 100% Covered After Deductible
Up to $125 per day, 100% Covered After Deductible
Convalescent Care Facility

50% of hospital semi-private room rate, up to 90 days for any one injury or sickness;

100% Covered After Deductible

50% of hospital semi-private room rate, up to 90 days for any one injury or sickness;

100% Covered After Deductible

50% of hospital semi-private room rate, up to 90 days for any one injury or sickness;

100% Covered After Deductible

50% of hospital semi-private room rate, up to 90 days for any one injury or sickness;

100% Covered After Deductible
Home Health Care
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
Hospice Care

Up to 210 days;

100% Covered After Deductible

Up to 210 days;

100% Covered After Deductible

Up to 210 days;

100% Covered After Deductible

Up to 210 days;

100% Covered After Deductible
In-Patient Mental Health Care

Up to 30 days per year;

100% Covered After Deductible

Up to 30 days per year;

100% Covered After Deductible

Up to 30 days per year;

100% Covered After Deductible

Up to 30 days per year;

100% Covered After Deductible
Out-Patient Mental Health

Up to 20 visits per year;

100% Covered After Deductible

Up to 20 visits per year;

100% Covered After Deductible

Up to 20 visits per year;

100% Covered After Deductible

Up to 20 visits per year;

100% Covered After Deductible
Mental Health treatment for biologically based mental illness
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
In-Patient ALC/SA Treatment

Up to 30 days per year. Up to 7 days per year in a detox facility;

100% Covered After Deductible

Up to 30 days per year. Up to 7 days per year in a detox facility;

100% Covered After Deductible

Up to 30 days per year. Up to 7 days per year in a detox facility;

100% Covered After Deductible

Up to 30 days per year. Up to 7 days per year in a detox facility;

100% Covered After Deductible
Out-Patient ALC/SA Treatment

Up to 60 visits per year, 20 visits may be for family members;

100% Covered After Deductible

Up to 60 visits per year, 20 visits may be for family members;

100% Covered After Deductible

Up to 60 visits per year, 20 visits may be for family members;

100% Covered After Deductible

Up to 60 visits per year, 20 visits may be for family members;

100% Covered After Deductible
Diabetic Equipment, Supplies, Self-management education
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
Foot Care (other than routine)

Up to $2000 per year;

100% Covered After Deductible

Up to $2000 per year;

100% Covered After Deductible

Up to $2000 per year;

100% Covered After Deductible

Up to $2000 per year;

100% Covered After Deductible
Organ Transplant

Up to $150,000 lifetime benefit;

100% Covered After Deductible

Up to $150,000 lifetime benefit;

100% Covered After Deductible

Up to $150,000 lifetime benefit;

100% Covered After Deductible

Up to $150,000 lifetime benefit;

100% Covered After Deductible
Infertility

Hospital, surgical, and medical care for the diagnosis and treatment of correctable medical conditions causing infertility;

100% Covered After Deductible

Hospital, surgical, and medical care for the diagnosis and treatment of correctable medical conditions causing infertility;

100% Covered After Deductible

Hospital, surgical, and medical care for the diagnosis and treatment of correctable medical conditions causing infertility;

100% Covered After Deductible

Hospital, surgical, and medical care for the diagnosis and treatment of correctable medical conditions causing infertility;

100% Covered After Deductible

Dependents
(Domestic Partners Not

covered)

Dep. Children to end of year in which they turn 18

---Students to end of year in which they turn 25

Dep. Children to end of year in which they turn 18

---Students to end of year in which they turn 25

Dep. Children to end of year in which they turn 18

---Students to end of year in which they turn 25

Dep. Children to end of year in which they turn 18

---Students to end of year in which they turn 25
Prosthetic devices
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
100% Covered After Deductible
Durable Medical Equip.
Not Covered
Not Covered
Not Covered
Not Covered
HSA Compatible
Yes
Yes
Yes
No

Rates & Benefits are for comparative purposes only.  Actual rate & benefit info and details must come directly from the insurance carrier.  $16 Administrative Fee Incl.

Plans Effective 9/1/08 through 8/31/09