Page 11 - GBS OE Brochure - Generic Hospitality

MEDICAL BENEFITS
Gold Medical Plan Summary
Bene t Plan Details
In-Network
Out-of-Network
Deductible (Annual)
$500 Individual / $1,000 Family
$500 Individual / $1,000 Family
Coinsurance (You Pay)
10% after Deductible
30% after Deductible
Out-of-Pocket Maximum
(Inc. Deductibles, Co-ins., and Copays)
$1,000 Individual / $2,000 Family
$2,000 Individual / $4,000 Family
Preventive Care Services
Covered 100%
30% after Deductible
Primary Care Of ce Visit
$25 Copay
Specialist Care Of ce Visit
$40 Copay
Hospital -Inpatient (per admission)
10% after Deductible
Outpatient Surgery
10% after Deductible
Emergency Room (per visit, waived if admitted)
$100 Copay
Urgent Care
$40 Copay
Prescription Drugs
Pharmacy Deductible
Individual $50 / Family $100
N/A
Pharmacy Out-of-Pocket Maximum
Individual $1,000 / Family $2,000
Retail (30 day supply)
$15 / $35 / $75
Mail Order (2 x retail for 90 day supply)
$30 / $70 / $150
Lifetime Maximum
Unlimited
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