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Plan Administration
Blue Cross Blue Shield of Georgia > Blue Care Network HMO > Edit Plan
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Broker Name:
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BrokerXYZ
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Policy Number:
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34512435
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Original Plan Effective Date:
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12/11/2002
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Rate Guarantee Expiration Date:
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12/11/2002
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Plan Anniversary Date:
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12/11/2202
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Billing Cut-off Day of the Month:
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25
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Retroactive Termination Limit:
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60
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Division:
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All Divisions
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Location:
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California
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Employee Classes:
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Full Time
Manager
Officer
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General Plan Information
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Annual Deductible
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- Individual
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$1000
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- Family
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$2500
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Coinsurance
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75%
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Office Visit/Exam
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$10 copay
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Annual Out-of-Pocket Limit
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- Individual
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$2000
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- Family
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$3000
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Lifetime Plan Maximum
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Unlimited
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Primary Physician Election Required
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Yes
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Preventive Services
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Well-Child Care and Immunizations
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$0
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Annual Pap or Prostate Exams
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$10 copay
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Mammograms
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$10 copay
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Prescription Drug Benefits
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Pharmacy/Walk-in
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- Formulary Based
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Yes
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- Generic
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$5 copay
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- Brand
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$10 copay
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- Non-Formulary
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$20 copay
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- Number of Days Supply
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14 days
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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.
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Employee Cost
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Company Cost
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Total
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Employee
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$6.82
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$77.16
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$83.98
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Employee + Spouse
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$24.32
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$88.60
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$112.92
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Employee + Child(ren)
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$117.31
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$45.32
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$162.63
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Family
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$154.15
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$230.21
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$384.36
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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
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