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Plan Description
Blue Cross Blue Shield of Georgia > Blue Care Network HMO

Note: This page contains a brief summary of coverage. It does not state all provisions and limitations of the plan. The terms and provisions of each plan, as outlined in the plan document, will determine coverage and eligibility.

Broker Name:	Blue Cross Blue Shield of Georgia
Policy Number:	34512435
Original Plan Effective Date:	12/11/2002
Rate Guarantee Expiration Date:	12/11/2002
Plan Anniversary Date:	12/11/2202
Billing Cut-off Day of the Month:	1
Retroactive Termination Limit:	30
Divisions:	All Divisions
Locations:	California
Employee Classes:	Full Time Manager Officer
Validation Method:	Automatic

Provider Directory:
http://www.yahoo.com/

General Plan Information
Annual Deductible
- Individual	$1000
- Family	$2500
Coinsurance	75%
Office Visit/Exam	$10 copay
Annual Out-of-Pocket Limit
- Individual	$2000
- Family	$3000
Out-of-Pocket Maximums Including Deductible	No
Lifetime Plan Maximum	Unlimited
Plan Accumulations	Plan Year
Primary Physician Election required	Yes
Preventive Services
Well-Child Care and Immunizations	$0
Adult Periodic Exams with Preventive Tests	$10 copay
Annual Pap or Prostate Exams	$10 copay
Mammograms	$10 copay
Physician Services
Office Visit	$10 copay
Specialist Visit	$10 copay
After Hours Physician Visit	$10 copay
Second Opinion	$10 copay
Diagnostic X-Ray and Lab Tests	$10 copay
Surgical Services	$10 copay
Pregnancy and Maternity Care (Pre-Natal Care)	$10 copay
Allergy Care
Diagnosis	$10 copay
Treatment	$10 copay
Inpatient Hospital Services
Pre-Authorization of Services required	Yes
Semi-Private Room & Board	$150 copay per admission
Newborn Delivery Services	$150 copay per admission
Outpatient Hospital Services
Outpatient Facility Services	$15 copay
Diagnostic Lab & X Ray	$15 copay
Emergency Services
Emergency Room	$25 copay
Ambulance	$50 copay
Urgent Care
In Urgent Care Facility	$20 copay
Mental Health Benefits
Inpatient Care	100% (60 days per year)
Outpatient Care
- Group Therapy	$20 copay
- Individual Therapy	$20 copay
Alcohol & Substance Abuse
Inpatient Hospitalization	Deductible/Coinsurance
Inpatient Detoxification Services	Deductible/Coinsurance
Outpatient Services
- Group Therapy	$20 copay
- Individual Therapy	$20 copay
Prescription Drug Benefits
Pharmacy/Walk-in
- Formulary Based	Yes
- Generic	$5 copay
- Brand	$10 copay
- Non-Formulary	$20 copay
- Number of Days Supply	14 days
- Oral Contraceptives	$20 copay
Mail Order
- Formulary Based	Yes
- Generic	$7 copay
- Brand	$12 copay
- Non-Formulary	$20 copay
- Number of Days Supply	60 days
- Oral Contraceptives	$20 copay
Other Services
Durable Medical Equipment	80%
Home Health Care	$20 copay
Skilled Nursing	Not Covered
Hospice Care	Not Covered
Chiropractic Services	Not Covered
Acupuncture	Not Covered
TMJ	Not Covered
Vision	Not Covered
Other Services and Supplies	Not Covered
Infertility
Diagnosis	50%
Treatment	50%
Outpatient Rehabilitative Therapy Services
Physical	$15 copay
Occupational	$15 copay
Speech	$15 copay
Additional Highlights
Additional Field One	Value One

Waiting Period Information
Eligible employees are eligible as of the 1st of the month following the employee's hire date.

Termination of Coverage Information
When a plan participant is terminated from the company, the plan coverage ends on the last day of the month following the employee's termination date.

(per month)

	Employee Cost	Company Cost	Total
Employee	$6.82	$77.16	$83.98
Employee + Spouse	$24.32	$88.60	$112.92
Employee + Child(ren)	$117.31	$45.32	$162.63
Family	$154.15	$230.21	$384.36

http://www.bluesss.com

Member Services

Claims Services

- Summary Plan Description

- BCBSM Employee Enrollment (

Enrollment Related Form)

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Enrollment Related Form)

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