What the Plan Costs and Covers 2019

Summary of Benefits and Coverage:

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
In-network Out-of-network
Medical Care
PCP office visit $50 copay
$10 copay dependent children
Not covered
Specialist office visit $50 copay
$10 copay dependent children
Not covered
Diagnostic lab/X-ray $50 copay
$10 copay dependent children
Not covered
Preventive Care
Routine physical exam $0 copay Not covered
Well child care $0 copay Not covered
Women’s wellness services $0 copay Not covered
Other Services
Outpatient mental health $0 copay Not covered
Urgent care $75 copay Not covered
Ambulance You pay all charges after $100 Not covered
Prescription drugs $15 generic/$50 brand/$100 non-formulary copay/25% coinsurance up to $200 maximum per script for specialty drugs Not covered
Hospital Services
Inpatient care $500 copay per day/$1000 maximum Not covered
Emergency room $200 copay (waived if admitted) $200 copay (waived if admitted)
Ambulatory surgery $150 copay Not covered

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