|
|
|
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:
|
BrokerXYZ
|
|
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
|
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
|
|
Lifetime Plan Maximum
|
Unlimited
|
|
Primary Physician Election required
|
Yes
|
Preventive Services
|
|
Well-Child Care and Immunizations
|
$0
|
|
Annual Pap or Prostate Exams
|
$10 copay
|
|
Mammograms
|
$10 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
|
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.
|
|
|
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
|
|
Plan Name HMO
http://www.bluesss.com
Member Services
John Carpet
600 Lafayette East
Detroit, MI 48226
(313) 225-5890
Fax (313) 225-3453
Claims Services
Jennifer Pattern
600 Lafayette East
Detroit, MI 48226
(313) 225-3445
Fax (313) 225-3435
|
|
