Summary of Benefits and Coverage:
What the Plan Covers and Costs

GHI HMO | GHI HMO with Rx

Benefits Summary: GHI HMO
Medical Care Your In-Network Cost
PCP office visit $15 copay
Specialist office visit $15 copay
Diagnostic lab $0 copay
X-ray $15 copay
Routine physical exam $15 copay
Well child care $0
Outpatient mental health $15 copay
Urgent care $15 copay
Ambulatory surgery $0
Ambulance $0
Inpatient care $0
Anesthesia $0
Emergency room $35 copay (waived if admitted)

Additional Riders

You can add the following benefit to your GHI HMO plan through a payroll deduction:

  • Prescription drugs (for generic and brand drugs from network retail drug stores and home delivery service)