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%
Adult 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 benefits booklet for a comprehensive description of plan benefits. Under all circumstances, the benefits booklet will take precedence over information contained on this website.  You can access the 2014 Group Health Benefits Booklet at: 2014 GHC Booklet.  

 

Last modified on Wednesday, August 06, 2014