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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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Open Access POS Plans

PW_E240113

Rx Option K Plans - Benefit Summaries (effective 1/1/2016)

GBF OAP9 2.5K 20 K 
GBF OAP9 3.5K 20 K 
GBF OAP9 5K 20 K 
GBF OAP9 6.35K 0 K 
GBF OAP5 1.5K 0 K 
GBF OAP5 1.5K 10 K 
GBF OAP5 1.5K 20 6.6K K 
GBF OAP5 1.5K 20 K 
GBF OAP5 1K 0 K 
GBF OAP5 1K 10 K 
GBF OAP5 1K 20 4K K 
GBF OAP5 1K 20 K 
GBF OAP5 2.5K 0 K 
GBF OAP5 2.5K 20 K 
GBF OAP5 2K 0 6.6K K 
GBF OAP5 2K 0 K 
GBF OAP5 3.5K 0 K 
GBF OAP5 3.5K 20 K 
GBF OAP5 500 0 K 
GBF OAP5 500 10 4.4K K 
GBF OAP5 500 20 2K K 
GBF OAP5 500 20 4.4K K 
GBF OAP5 500 20 K 
GBF OAP5 5K 0 K 
GBF OAP5 6.35K 0 K 
 
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