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click here for page 2 (more BC HMO plan options)
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Page 1 click here for page 2 (more BC HMO plan options) |
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| Description of Benefits |
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| Lifetime Maximum |
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Calendar
year Deductible (per member-max 3 members) |
In-Network |
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| Coinsurance | In-Network |
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Out-of-Pocket
Maximum for Calendar Year - Includes Deductible (per member-max 3 members) |
In-Network |
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Physicians
Office Visit PCP/Specialist (includes x-ray and lab work done and billed by Drs. office) |
In-Network |
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Outpatient
Diagnostic X-ray/Lab (Plan pays after deductible) |
In-Network |
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Outpatient
Surgery Facility
includes
x-ray and lab (Plan pays after deductible) |
In-Network |
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Physician
Outpatient Services (surgeon,
radiologist, anesthesiologist, etc) (Plan pays after deductible) |
In-Network |
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Maternity (physician fee only) |
In-Network (1st visit only) |
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Inpatient
Hospital (Plan pays after deductible) |
In-Network |
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Physician
Inpatient Services (surgeon,
radiologist, anesthesiologist, etc) (Plan pays after deductible) |
In-Network |
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Physical
and Occupational Therapy 20 visits allowed per year |
In-Network |
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Chiropractic
Care 20 visits allowed per year |
In-Network |
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Inpatient
Behavioral Health/Substance Abuse 30 Day calendar year max (Plan pays after deductible) |
In-Network |
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Outpatient
Behavioral Health/Substance Abuse 20 Visit calendar year max |
In-Network |
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Emergency
Room Copay |
In or Out of Network |
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Prescription
Drug Copays |
Prescription deductible per member (calendar yr) |
$0 |
$0 |
$0 |
$0 |
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Generic/Formulary |
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Brand/Formulary |
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Non-Formulary |
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Mail Order |
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| Note: Plan benefits listed above are intended as a summary only and do not replace benefits listed in certificate of coverage. Some specific benefits may have limitations and/or exclusions. Refer to your policy for more detail. | |||||
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Click
here for more Blue Cross HMO plans and benefits Click here for Blue Cross Group PPO plans and benefits Click here for Blue Cross Group POS plans and benefits |
Click
here for Blue Cross Group Dental plans Click here for Individual Plan Options |
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 5 Dunwoody Park South, Suite 110 Atlanta, GA 30338 |
(770) 396-9517 Outside of the Atlanta area, call toll-free: 1-877-711-8376. Email: bryals@mindspring.com |
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