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Sample
GHI EPO (no referrals)
Rx - $0/30/50 $750 retail max unlimited mail
order.
Office Copay- $30
ER - $100
Diagnostics/ Labs - $30
Lifetime Max
-unlimited
Hospitalization-
$1000/year max. $500 deductible = 10% of $5,000
Well Child Care until
19-$0
copay
Routine Adult Care -
$0 copay
-Annual Physical
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Single-$322.63
Family-$825.72 |
3rd
Quarter Only
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