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Group Health Plan – POS 100-60 3000 NM – MISSOURI

A comparison of the POS 100-60 3000 NM offered by Group Health Plan is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Application	POS 100-60 3000 NM Application	POS 100-60 3000 NM Application
Brochure	POS 100-60 3000 NM Brochure	POS 100-60 3000 NM Brochure
Copay	Primary Care Provider Office Visit: $30 Specialist Office Visit: $30	N/A
Office Visit	Primary Care Provider Office Visit: $30 Specialist Office Visit: $30	Primary Care Provider Office Visit: 60% after deductible Specialist Office Visit: 60% after deductible
Deductible	$3,000	$9,000
Coinsurance	100%	60%
Coinsurance Limit	N/A	$6,000
Out-of-Pocket Maximum	N/A	$15,000
Lifetime Maximum	POS 100-60 3000 NM	POS 100-60 3000 NM
Prescription Drugs	Pharmacy - Tier One: $15 Tier Two: $40 Tier Three: $65 Mail Order (90-day supply): 2x	Pharmacy - Tier One: $15 Tier Two: $40 Tier Three: $65 Mail Order (90-day supply): 2x
Emergency Room	Urgent Care: $75 Emergency Department: $250	Urgent Care: $75 Emergency Department: $250
Adult Preventative Care	POS 100-60 3000 NM	POS 100-60 3000 NM
Child Preventative Care	POS 100-60 3000 NM	POS 100-60 3000 NM
Lab / X-Ray	POS 100-60 3000 NM	POS 100-60 3000 NM
Maternity	Not covered	Not covered
Physical Therapy	Not covered	Not covered
Skilled Nursing	Not covered	Not covered
Home Health Care	POS 100-60 3000 NM	POS 100-60 3000 NM
Mental Health	Not covered	Not covered
Hospital Care	Inpatient/Outpatient Surgery: 100% after deductible	Inpatient/Outpatient Surgery: 60% after deductible
Optional Benefits	N/A	N/A