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Plan Description
Blue Cross Blue Shield of Georgia > Infinity Resources, Inc. PPO
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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.
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Broker Name:
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Cigna Healthcare
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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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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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PCP In
Network
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Preferred In
Network
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Out of
Network
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General Plan Information
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Annual Deductible
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- Individual
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$500
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$1000
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$2000
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- Family
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$2500
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$3000
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Not Applicable
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Coinsurance
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75%
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90%
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Not Applicable
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Office Visit/Exam
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$10 copay
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$15 copay
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Deductible/Coinsurance
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Annual Out-of-Pocket Limit
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- Individual
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$1500
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$1000
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$500
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- Family
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$3000
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$2500
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$1500
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Lifetime Plan Maximum
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Unlimited
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$2,000,000
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$500,000
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Primary Physician
Election Required
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Yes
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Yes
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Yes
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Preventive Services
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Well-Child Care and
Immunizations
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$10 copay
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$10 copay
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$15 copay
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Adult Periodic Exams with
Preventive Tests
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$10 copay
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$10 copay
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$20 copay
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Annual Pap or Prostate Exams
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$10 copay
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$10 copay
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$15 copay
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Mammograms
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$10 copay
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$15 copay
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Deductible/Coinsurance
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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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Yes
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Yes
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- Generic
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$5 copay
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$8 copay
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Deductible/Coinsurance
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- Brand
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$10 copay
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$15 copay
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Deductible/Coinsurance
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- Non-Formulary
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$12 copay
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$15 copay
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Deductible/Coinsurance
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- Number of Days Supply
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14 days
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14 days
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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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(per month)
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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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Infinity Resources, Inc. PPO
http://www.wppo.com
Member Services
John Carpet
600 Lafayette East
Detroit, MI 48226
(313) 225-5890
Fax 345-133-4433
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