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Plan Administration


Plan Description
Blue Cross Blue Shield of Georgia > Infinity Resources, Inc. PPO

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.


Availability
    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
Plan Highlights
  Provider Directory:
   http://www.yahoo.com/
      PCP In
    Network         		Preferred In
    Network         		Out of
    Network
    General Plan Information

    Annual Deductible
        - Individual $500 $1000 $2000
        - Family $2500 $3000 Not Applicable
    Coinsurance 75% 90% Not Applicable
    Office Visit/Exam $10 copay $15 copay Deductible/Coinsurance
    Annual Out-of-Pocket Limit
        - Individual $1500 $1000 $500
        - Family $3000 $2500 $1500
    Lifetime Plan Maximum Unlimited $2,000,000 $500,000
    Primary Physician
    Election required         		Yes Yes Yes

    Preventive Services

    Well-Child Care and
    Immunizations         		$10 copay $10 copay $15 copay
    Adult Periodic Exams with
    Preventive Tests         		$10 copay $10 copay $20 copay
    Annual Pap or Prostate Exams $10 copay $10 copay $15 copay
    Mammograms $10 copay $15 copay Deductible/Coinsurance

    Physician Services

    Office Visit $10 copay $15 copay Deductible/Coinsurance

    Outpatient Services

    Diagnostic X-Ray and
    Lab Tests         		$10 copay $15 copay $20 copay
    Pregnancy and
    Maternity Care
    (Pre-Natal Care)         		$10 copay $15 copay $20 copay

    Inpatient Hospital Services

    Pre-Authorization of
    Services required         		Yes Yes Yes
    Semi-Private Room & Board $150 copay
    per admission     		$240 copay
    per admission     		$350 copay
    per admission

    Outpatient Hospital Services

    Outpatient Facility Services $10 copay $15 copay $20 copay

    Emergency Services

    Emergency Room $50 copay $70 copay Deductible/Coinsurance

    Urgent Care

    In Urgent Care Facility $15 copay $20 copay $50 copay

    Mental Health Benefits

    Inpatient Care 100%
    (60 days per year)     		100%
    (45 days per year)     		$240 copay
    per admission
    Outpatient Care
        - Group Therapy $10 copay $15 copay $20 copay
        - Individual Therapy $10 copay $15 copay $20 copay

    Alcohol & Substance Abuse

    Inpatient Hospitalization $150 copay $250 copay Deductible/Coinsurance
    Inpatient Detoxification Services $150 copay $250 copay Deductible/Coinsurance
    Outpatient Services
        - Group Therapy $10 copay $15 copay $20 copay
        - Individual Therapy $10 copay $15 copay $20 copay

    Prescription Drug Benefits

    Pharmacy/Walk-in
        - Formulary Based Yes Yes Yes
        - Generic $5 copay $8 copay Deductible/Coinsurance
        - Brand $10 copay $15 copay Deductible/Coinsurance
        - Non-Formulary $12 copay $15 copay Deductible/Coinsurance
        - Number of Days Supply 14 days 14 days 14 days
        - Oral Contraceptives $12 copay $15 copay Deductible/Coinsurance
    Mail Order
        - Formulary Based Yes Yes Yes
       - Generic $7 copay $10 copay Deductible/Coinsurance
       - Brand $8 copay $12 copay Deductible/Coinsurance
       - Non-Formulary $10 copay $15 copay Deductible/Coinsurance
        - Number of Days Supply 90 days 60 days 60 days
        - Oral Contraceptives $12 copay $15 copay Deductible/Coinsurance

    Other Services

    Durable Medical Equipment 80% Not Covered Not Covered
    Home Health Care $15 copay $20 copay Not Covered
    Skilled Nursing $15 copay $20 copay Not Covered
    Hospice Care Not Covered Not Covered Not Covered

    Infertility

    Diagnosis $10 copay 50% Not Covered
    Treatment $10 copay 50% Not Covered

    Outpatient Rehabilitative Therapy Services

    Physical $10 copay $15 copay $20 copay
    Occupational $15 copay $20 copay Not Covered
    Speech $15 copay $20 copay Not Covered

    Additional Information

    Additional Field One A Value One B Value One C Value One
    Additional Field Two A Value two B Value two C Value two
Eligibility

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.

Cost 0
  (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

Contacts
    Cigna Flexcare EPP
    http://www.wppo.com

    Member Services
    John Carpet
    600 Lafayette East
    Detroit, MI 48226
    (313) 225-5890
    Fax 345-133-4433
Forms
- Summary Plan Description
- BCBSM Employee Enrollment  ( Enrollment Related Form)
- Coordination of Benefits

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