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

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Open Access POS Plans

PW_G313594

Rx Option KE Plans – Benefit Summaries (effective 1/1/2018)

Fully Insured Groups 
GBF OAP5 500 0 KE  
GBF OAP5 500 0 7.15K KE  
GBF OAP5 500 10 4.4K KE  
GBF OAP5 500 10 KE  
GBF OAP5 500 20 2K KE 
GBF OAP5 500 20 4.4K KE 
GBF OAP5 500 20 KE 
GBF OAP5 1K 0 KE 
GBF OAP5 1K 0 7.15K KE  
GBF OAP5 1K 10 4K KE 
GBF OAP5 1K 20 4K KE 
GBF OAP5 1.5K 0 KE 
GBF OAP5 1.5K 0 7.15K KE 
GBF OAP5 1.5K 10 KE 
GBF OAP5 1.5K 10 7.15K KE 
GBF OAP5 1.5K 20 7.15K KE 
GBF OAP5 1.5K 20 KE 
GBF OAP5 2K 0 7.15K KE 
GBF OAP5 2K 0 KE 
GBF OAP5 2.5K 0 KE 
GBF OAP5 2.5K 0 7.15K KE 
GBF OAP5 2.5K 20 KE 
GBF OAP5 3K 20 7.15K KE 
GBF OAP5 3.5K 0 KE 
GBF OAP5 3.5K 0 7.15K KE 
GBF OAP5 3.5K 20 KE 
GBF OAP5 3.5K 30 KE  
GBF OAP5 5K 0 KE 
GBF OAP5 5K 0 7.15K KE 
GBF OAP5 5K 30 KE 
GBF OAP5 5K 20 7.15K KE 
GBF OAP5 6K 20 7.15K KE 
GBF OAP5 6.35K 0 KE 
GBF OAP9 2.5K 20 KE 
GBF OAP9 3.5K 20 KE 
GBF OAP9 5K 20 KE 
GBF OAP9 6.35K 0 KE 
 
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