Group Health HMO
| Benefit |
| Deductible |
None
|
| Annual Out of Pocket Max |
$2,000 individual/$4,000 family
|
| Lifetime maximum benefit |
Unlimited
|
| Office Visits |
100% after $20 copay
|
| Preventive Care |
| Immunizations |
100%
|
| Routine physicals |
100%
|
| Well-woman exams/screenings |
100%
|
| Well-baby exams |
100%
|
| Other Care |
Emergency Room
(copay waived if admitted) |
$100 copay
|
| Inpatient hospital services |
100%
|
| Outpatient hospital services |
100% after $20 copay
|
| Outpatient surgical center |
100% after $20 copay
|
| Prescription drugs (retail/pharmacy) |
30-day supply
|
| Generic |
$10 copay
|
| Brand formulary |
$25 copay
|
| Nonformulary |
N/A
|
| Prescription drugs (mail order) |
90-day supply
|
| Generic |
$20 copay
|
| Brand formulary |
$50 copay
|
| Nonformulary |
N/A
|
This is a brief outline of the benefits provided. Refer to the Summary of Benefits and Coverages or the official Certificate of Coverage for a comprehensive description of plan benefits. Under all circumstances, the Certificate of Coverage will take precedence over information contained on this website. You can access the 2012 Certificate of Coverage at: 2012 GHC Certificate.
Last modified on Friday, February 15, 2013