PLANS |
PLAN 1 |
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| MONTHLY PREMIUM Domestic Partners Covered with supporting documentation To see Domestic Partners requirements, please click on the link below Domestic Partners Policy and Forms |
Single Rate $338.12 2-50 GROUP RATES: Single: $296.16 Family: $828.46 |
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| Allowed Charges | GHI Fee Schedule |
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Deductible Individual/Family |
$5,800/$11,600 |
$5,000/$10,000 |
$2,500/$5,000 |
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Coinsurance |
100% |
100% |
80% insurance company |
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Out of Pocket Maximum |
$5,800/$11,600 |
$5,000/$10,000 |
$4,500/$7,000 |
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Annual Physical Check-up (Adult) (WELL VISITS ONLY!) |
Covered in full |
Covered in full |
Covered in full |
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Diagnostic/Lab Fees |
Covered in full after deductible |
Covered in full after deductible |
Covered in full after deductible & coinsurance |
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Inpatient Hospital and inpatient medical services (precertification required) |
Covered in full after deductible |
Covered in full after deductible |
Covered in full after deductible & coinsurance |
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Drug Card |
Covered in full after deductible |
Covered in full after deductible |
Rx subject to deductible and coinsurance, then: Retail: $0/$20/$40 Mailaway: $0/$40/$80 Unlimited Annual Retail Max Pre-Authorization required for Managed Program |
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Lifetime Maximum |
Unlimited |
Unlimited |
Unlimited |
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In Patient Hospital Coverage |
Precertification required 365 days/confinement |
Precertification required 365 days/confinement |
Precertification required 365 days/confinement Covered in full after deductible & co-ins |
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Skilled Nursing Facility Care |
Precertification required Covered in full after deductible |
Precertification required Covered in full after deductible |
Precertification required Covered in full after deductible & coinsurance |
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In Patient Medical Rehab (Ie: PT, Physical Medicine & Rehab) |
Precertification required 30 days/calendar yr Covered in full after deductible |
Precertification required 30 days/calendar yr Covered in full after deductible |
Precertification required 30 days/calendar yr Subject to deductible & co-ins |
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Hospice: In or Out Patient |
Precertification required 210 days/lifetime Subject to deductible |
Precertification required 210 days/lifetime Subject to deductible |
Precertification required 210 days/lifetime Subject to deductible & co-ins |
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Pre-Admission Outpatient Hospital Testing |
Covered in full after deductible |
Covered in full after deductible |
Subject to deductible & coinsurance |
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Outpatient Ambulatory Surgery Facility Charge (free standing or OPD hospital) |
Precertification required Covered in full after deductible |
Precertification required Covered in full after deductible |
Precertification required Subject to deductible & coinsurance
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Outpatient Home Health Care Services |
Precertification required 200 visits/calendar yr Covered in full after deductible |
Precertification required 200 visits/calendar yr Covered in full after deductible |
Precertification required 200 visits/calendar yr Subject to deductible & co-ins |
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Outpatient Diagnostic Lab/Radiology |
Precertification required for Radiology services Covered in full after deductible |
Precertification required for Radiology services Covered in full after deductible |
Precertification required for Radiology services Subject to deductible & coinsurance |
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Outpatient Preventative Mammography and Pap Smear & Prostate Screening |
Covered in full after deductible |
Covered in full after deductible |
Subject to deductible & coinsurance |
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Office Visits & Diagnostic Copay for Dependent Child(ren) |
Covered in full after deductible |
Covered in full after deductible |
Subject to deductible & coinsurance |
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Office Visit Copay, Including Outpatient Clinic Visits |
Covered in full after deductible |
Covered in full after deductible |
Subject to deductible & coinsurance |
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| Specialist Office Visits | Covered in full after deductible |
Covered in full after deductible |
Subject to deductible & coinsurance |
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| Maternity Pre-Postnatal Care | Covered in full after deductible |
Covered in full after deductible |
Subject to deductible and coinsurance |
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| Preventive Mammography and Pap Smear & Prostate Screening (In Office Only) | Covered in Full |
Covered in Full |
Subject to deductible and coinsurance |
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| Chiropractic Care | Covered in full after deductible |
Covered in full after deductible |
Subject to deductible & co-ins |
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Outpatient & Inpatient Surgery |
Precertification Required Covered in full after deductible | Precertification Required Covered in full after deductible | Precertification Required Subject to deductible and coinsurance |
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| DME | Precertification required when amt is >$2,000 $10,000 Calendar year max Deductible applies |
Precertification required when amt is >$2,000 $10,000 Calendar year max Deductible applies |
Precertification required when amt is >$2,000 $10,000 Calendar year max Deductible & co-ins applies |
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| Diagnostic Lab^ | Providers office/Free Standing Facility Covered in full after deductible |
Providers office/Free Standing Facility Covered in full after deductible |
Providers office/Free Standing Facility Subject to deductible and coinsurance |
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| Diagnostic Radiology^ | Precertification required Providers office/Free standing Facility Covered in full after deductible |
Precertification required Providers office/Free standing Facility Covered in full after deductible |
Precertification required Providers office/Free standing Facility Subject to deductible and co-insurance |
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Well Baby/Well Child Care Incl. Immunizations |
Up to age 19 Covered in full |
Up to age 19 Covered in full |
Up to age 19 covered in full |
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| ER Facility Copay | Covered in full after deductible |
Covered in full after deductible | Subject to deductible and coinsurance |
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| Emergency Ground Ambulance | Covered up to 100% of U&C, Deductible applies |
Covered up to 100% of U&C, Deductible applies | Covered up to 100% of U&C, Deductible & Co-ins applies |
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| Inpatient Mental Health | Precertification required 30 days/calendar yr No limits for biological based Covered in full after deductible |
Precertification required 30 days/calendar yr No limits for biological based Covered in full after deductible |
Precertification required 30 days/calendar yr No limits for biological based Subject to deductible & co-ins |
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| Inpatient Chemical Dependency Detox | Precertification required 7 days/calendar yr Covered in full after deductible |
Precertification required 7 days/calendar yr Covered in full after deductible |
Precertification required 7 days/calendar yr Subject to deductible & co-ins |
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| Inpatient Chemical Dependency Rehab | Precertification required 30 days/calendar yr Covered in full after deductible |
Precertification required 30 days/calendar yr Covered in full after deductible |
Precertification required 30 days/calendar yr Subject to deductible & co-ins |
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| Outpatient Chemical Dependency | Precertification required 60 visits/calendar yr Up to 20 family visits Covered in full after deductible |
Precertification required 60 visits/calendar yr Up to 20 family visits Covered in full after deductible |
Precertification required 60 visits/calendar yr Up to 20 family visits Subject to deductible & co-ins |
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| Outpatient Mental Health | Precertification required 30 visits/calendar yr No limits for biological based Covered in full after deductible |
Precertification required 30 visits/calendar yr No limits for biological based Covered in full after deductible |
Precertification required 30 visits/calendr yr No limits for biological based Subject to deductible & co-ins |
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Dependents |
Dep. Children to end of month in which they turn 26 |
Dep. Children to end of month in which they turn 26 |
Dep. Childred to end of month in which they turn 26 |
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Plans Effective 09/01/11 through 08/31/12 |
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