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Plan Administration
Blue Cross Blue Shield of Georgia > Blue Care Network HMO > Edit Plan


Please complete as much information as possible. For most fields, you can either type a value or click in the list on the right to select a pre-defined value.

Plan Highlights
    General Plan Information


    Annual Deductible/Individual



    Annual Deductible/Family



    Coinsurance




    Office Visit/Exam




    Annual Out-of-Pocket Limit/Individual




    Annual Out-of-Pocket Limit/Family




    Out-of-Pocket Maximums Including Deductible




    Lifetime Plan Maximum




    Plan Accumulations




    Primary Physician Election required





    Preventive Services


    Well-Child Care and Immunizations




    Adult Periodic Exams with Preventive Tests




    Annual Pap or Prostate Exams




    Mammograms





    Physician Services


    Office Visit




    Specialist Visit




    After Hours Physician Visit




    Second Opinion




    Diagnostic X-Ray and Lab Tests




    Surgical Services




    Pregnancy and Maternity Care (Pre-Natal Care)





    Allergy Care


    Diagnosis




    Treatment




    Inpatient Hospital Services


    Pre-Authorization of Services required




    Semi-Private Room & Board




    Newborn Delivery Services





    Outpatient Hospital Services


    Outpatient Facility Services




    Diagnostic Lab & X Ray





    Emergency Services


    Emergency Room




    Ambulance




    Is Copay Waived If Admitted?





    Urgent Care


    In Urgent Care Facility





    Mental Health Benefits


    Inpatient Care




    Outpatient Care
    Group Therapy



    Individual Therapy





    Alcohol & Substance Abuse


    Inpatient Hospitalization




    Inpatient Detoxification Services




    Outpatient Services
    Group Therapy



    Individual Therapy





    Prescription Drug Benefits


    Pharmacy/Walk-in
    Formulary Based



    Generic



    Brand



    Non-Formulary



    Number of Days Supply



    Oral Contraceptives




    Mail Order
    Formulary Based



    Generic



    Brand



    Non-Formulary



    Number of Days Supply



    Oral Contraceptives





    Other Services


    Durable Medical Equipment




    Home Health Care




    Skilled Nursing




    Hospice Care




    Chiropractic Services




    Acupunture




    TMJ




    vision




    Other Services and Supplies





    Infertility


    Diagnosis




    Treatment





    Outpatient Rehabilitative Therapy Services


    Physical




    Occupational




    Speech





    Add Highlights   (optional)




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