PLANS & SERVICES FOR FEDERAL EMPLOYEES
Benefits at a Glance (2017)
This is a summary of the features of the GlobalHealth Plan. Before making a final decision, please read the Plan’s Federal Brochure, RI 73-834. All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure.
|BENEFIT||FEHB High Option Plan||FEHB Standard Option Plan|
|Annual Deductible*||This plan doesn’t have an annual deductible.||Self Only - $300
Self Plus One - $600
Self and Family - $600
|Annual out-of-pocket maximum||Self Only - $5,000
Self Plus One - $7,000
Self Plus Family - $7,000
|Self Only - $6,500
Self Plus One - $7,500
Self and Family - $7,500
|Primary Care Physician Visits||$0 copay per visit||$0 copay per visit|
|Specialist Physician Visits||$35 copay per visit||$45 copay per visit|
|Preventive Care/Well Child Visits||$0 copay||$0 copay|
|X-Rays & Labs||$0 copay||$0 copay|
|Specialized Scans, Imaging & Diagnostic Exams||$250 copay per scan in a preferred facility; $500 copay per scan in a non-preferred facility||$350 copay per scan in a preferred facility; $700 copay per scan in a non-preferred facility|
|Inpatient Hospital Stay||$250 copay per day with $750 maximum per admission||$500 copay per day with $1,500 maximum per admission|
|Outpatient Surgery||$250 copay in a preferred facility; $750 copay in a non-preferred facility||$500 copay in a preferred facility; $1,000 copay in a non-preferred facility|
|Emergency Room Service||$250 copay, waived if admitted to hospital inpatient||$300 copay, waived if admitted to hospital inpatient|
|Urgent Care||$25 copay in urgent care facility||$45 copay in urgent care facility|
Prescription Drugs (Chickasaw Nation Refill Center is a home delivery option for Native American members. Click here for more information.)
Preferred Network Retail Pharmacy $4/$12/$50/$80/10% up to $150/10% up to $250
Non-Preferred Network Retail Pharmacy $9/$17/$55/$85/10% up to $150/10% up to $250
Preferred Home Delivery or Extended Supply Retail $8/$24/$125/$240
Non-Preferred Home Delivery or Extended Supply Retail $13/$29/$130/$245
Preferred Network Retail Pharmacy $6/$15/$70/$105/10% up to $200/10% up to $300
Non-Preferred Network Retail Pharmacy $11/$20/$75/$110/10% up to $200/10% up to $300
Preferred Home Delivery or Extended Supply Retail $12/$30/$150/$270
Non-Preferred Home Delivery or Extended Supply Retail $17/$35/$155/$275
|Maternity Care||$0 copay for prenatal care; $25 one-time copay for delivery and all post-natal care; $250 copay per admission for delivery||$0 copay for prenatal care; $45 one-time copay for delivery and all post-natal care; $300 copay per day with $900 maximum per admission for delivery|
|Family Planning||No copay on FDA-approved services;||No copay on FDA-approved services;|
|Allergy Care||$0 copay per PCP visit; $35 copay per specialist visit; $0 copay for antigen and administration||$0 copay per PCP visit; $45 copay per specialist visit; $0 copay for antigen and administration|
|Physical, Occupational, Speech Therapy (Limited to 60 combined visits per course of therapy.)||Inpatient: $0 copay Outpatient: $30 copay per visit||Inpatient: $0 copay Outpatient: $45 copay per visit|
|Chiropractic Care (20 visits per year)||$20 copay per visit||$25 copay per visit|
|Mental Health Services, Chemical Dependency & Substance Abuse||$0 copay per outpatient office visit; $250 copay/day with $750/admission maximum||$0 copay per outpatient office visit; $500 copay/day with $1,500/admission maximum|
* No deductible on high option plan. Standard option plan deductible does not apply to PCP, specialist and behavioral health office visits, lab/x-ray, urgent care, preventive care and prescription drugs.
Exclusions and Limitations
The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in your Plan brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose or treat your illness, disease, injury or condition.
We do not cover the following:
- Care by non-Plan providers except for authorized referrals or emergencies (see Emergency services/accidents in the FEHB brochure).
- Services, drugs, or supplies you receive while you are not enrolled in this Plan.
- Services, drugs, or supplies not medically necessary.
- Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
- Experimental or investigational procedures, treatments, drugs, or devices (see specifics regarding transplants in the FEHB brochure).
- Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
- Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
- Services, drugs, or supplies you receive without charge while in active military service.
- Services, drugs, or supplies you would not be charged for if you had no health insurance.
- Services that you get without a referral from your primary care physician, when a referral from your primary care physician is required for getting that service.
- Services that you get without prior authorization, when prior authorization is required for getting that service.
- Emergency facility services for non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency.
- Personal convenience items, such as a telephone or television in your room at a hospital or skilled nursing facility.
- Nursing care on a full-time basis in your home.
- Custodial care is not covered by GlobalHealth unless it is provided in conjunction with skilled nursing care and/or skilled rehabilitation services. “Custodial care” includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered.
- Homemaker services.
- Meals delivered to your home.
- Charges imposed by immediate relatives or members of your household.
- Elective or voluntary enhancement procedures, services, supplies, and medications including but not limited to: Hair growth, athletic performance, cosmetic purposes, anti-aging, and mental performance.
- Cosmetic surgery or procedures, unless it is needed because of accidental injury or to improve the function of a malformed part of the body. Breast surgery and all stages of reconstruction for the breast on which a mastectomy was performed and, to produce a symmetrical appearance, surgery and reconstruction of the unaffected breast, is covered.