Blue Cross HMO Insurance Plans in Georgia

2005 Small Group Plan Designs

HMO
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Description of Benefits		2005 Small Group HMO Plan Options
Description of Benefits		3003SX	3500SX	3800SX

Lifetime Maximum		Unlimited	Unlimited	Unlimited

Calendar year Deductible (per member-max 3 members)	In-Network	$1,500	$1,000	$2,000

Coinsurance	In-Network	100%	80%	70%

Out-of-Pocket Maximum for Calendar Year - Includes Deductible (per member-max 3 members)	In-Network	$1,500	$3,000	$5,000

Physicians Office Visit PCP/Specialist (includes x-ray and lab work done and billed by Drs. office)	In-Network	$40/$40	$40/$40	$40/$40

Outpatient Diagnostic X-ray/Lab (Plan pays after deductible)	In-Network	100%	80%	70%

Outpatient Surgery Facility includes x-ray and lab (Plan pays after deductible)	In-Network	$100	$500 copay per adm; 80%	$1,000 copay per adm; 70%

Physician Outpatient Services (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	In-Network	100%	80%	70%

Maternity (physician fee only)	In-Network (1st visit only)	$40	$500	$1,000

Inpatient Hospital (Plan pays after deductible)	In-Network	100%	$500 copay per adm; 80%	$1,000 copay per adm; 70%

Physician Inpatient Services (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	In-Network	100%	80%	70%

Physical and Occupational Therapy 20 visits allowed per year	In-Network	$40	$40	$40

Chiropractic Care 20 visits allowed per year	In-Network	$15	$15	$15

Inpatient Behavioral Health/Substance Abuse 30 Day calendar year max (Plan pays after deductible)	In-Network	100%	$500 copay per adm; 80%	$1,000 copay per adm; 70%

Outpatient Behavioral Health/Substance Abuse 20 Visit calendar year max	In-Network	$40	$40	$40

Emergency Room Copay (waived if admitted)	In or Out of Network	$100	$150	$150

Prescription Drug Copays	Prescription deductible per member (calendar yr)	$0	$0	$250
	Generic/Formulary	$20	$20	$20
	Brand/Formulary	$35	$35	$35
	Non-Formulary	$60	$60	Not Covered
	Mail Order	$60	$60	$60

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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5 Dunwoody Park South, Suite 110 Atlanta, GA 30338	Call Bob, Holly or Terri at (770) 396-9517 Outside of the Atlanta area, call toll-free: 1-877-711-8376. Email: bryals@mindspring.com