What the Plan Costs and Covers

Summary of Benefits and Coverage:

GHI PPO High Option | GHI EPO Standard Option

If you have questions about your plan benefits or would like to request a free printed copy of the SBC, please call the number on the back of your member ID card, from 8 am to 8 pm, seven days a week (excluding major holidays). If you have a hearing or speech impairment and use a TDD, call 711.

Benefits At-a-Glance: GHI FEHB High Option and Standard Option

  Standard Option High Option
In-network Out-of-network In-network Out-of-network
Medical Care
PCP office visit $30 copay Not covered $20 copay 50% of plan’s fee schedule
Specialist office visit $30 copay Not covered $20 copay 50% of plan’s fee schedule
Diagnostic lab/X-ray $30 copay Not covered $20 copay 50% of plan’s fee schedule
Preventive Care
Routine physical exam $0 copay Not covered $0 copay 50% of plan’s fee schedule
Well child care $0 copay Not covered $0 copay 50% of plan’s fee schedule
Women’s wellness services $0 copay Not covered $0 copay 50% of plan’s fee schedule
Other Services
Outpatient mental health $0 copay Not covered $0 copay 50% of plan’s fee schedule
Urgent care $30 copay Not covered $20 copay 50% of plan’s fee schedule
Ambulance You pay all charges after $100 Not covered You pay all charges after $100 You pay all charges after $100
Prescription drugs $10 generic/$45 brand/$85 non-formulary copay/25% coinsurance up to $150 maximum per script for specialty drugs Not covered $20 generic/$45 brand/$85 non-formulary copay/25% coinsurance up to $150 maximum per script for specialty drugs Not covered
Hospital Services
Inpatient care $250 copay per day/$750 maximum Not covered $200 copay per day/$600 maximum
50% of plan’s fee
Emergency room $150 copay (waived if admitted) $150 copay (waived if admitted) 150 copay (waived if admitted) $150 copay (waived if admitted)
Ambulatory surgery $50 copay Not covered $50 copay 50% of plan’s fee schedule

For complete details about the benefits available through these plans, please read the Federal RI 73-007