Page 12 - GBS OE Brochure - Generic Hospitality

MEDICAL BENEFITS
Gold In-Network Medical Plan Summary
Medical Plan Bene ts
In-Network
Deductible (Annual)
None
Coinsurance (You Pay)
0%
Out-of-Pocket Maximum
(Inc. Deductibles, Co-ins., and Copays)
$500 Individual / $1,000 Family
Preventive Care Services
Covered 100%
Primary Care Of ce Visit
$25 Copay
Specialist Care Of ce Visit
$40 Copay
Hospital -Inpatient (per admission)
$250 Copay
Outpatient Surgery
$100 Copay
Emergency Room (per visit, waived if admitted)
$100 Copay
Urgent Care
$40 Copay
Prescription Drugs
Pharmacy Deductible
Individual $50 / Family $100
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
12 ABC COMPANY | HOSPITALITY 2017 OPEN ENROLLMENT