GHO - 2024 Employee Benefit Guide (FINAL 6.26.2024) SP

MEDICAL BENEFITS

OPEN ACCESS PLUS EPO PLAN

BENEFIT

IN-NETWORK ONLY

Annual Deductible

Individual:

$3,000 $6,000 $7,000 $14,000

Family:

Out-of-Pocket Maximum

Individual:

Family:

Coinsurance

Employee 20%/ Cigna 80%

Lifetime Maximum

Unlimited

Preventive Care Adult Preventive Care Adult Annual Physical Exam Well-Child Care

Covered 100%

Outpatient Care Primary care physician office visits Specialist office visits Outpatient facility surgery Outpatient Lab & X-Ray Laboratory Services Magnetic Resonance Imaging (MRI) Hospital Care Physician’s and surgeon’s services Semi-private room and board Emergency Care Ambulance when medically necessary At hospital emergency room Urgent Care Maternity Care Prenatal and Post-natal care Hospital services for mother and child

$15 copay $25 copay 20% after deductible

20% after deductible 20% after deductible

20% after deductible 20% after deductible

20% after deductible $500 copay $50 copay

20% after deductible 20% after deductible

Mental Health Inpatient Outpatient

20% after deductible $15 copay

Durable Medical Equipment

20% after deductible

Prescription Drug Deductible Retail Pharmacy (30 day supply)

$100 Individual/$200 Family $15 Tier 1; $25 Tier 2 $50 Tier 3

Mail Order (90 day supply)

$45 Tier 1; $75 Tier 2 $150 Tier 3

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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