Blue Cross of Georgia POS Small Group Health Insurance Plan Designs

2005 Small Group Plan Designs

POS
Page 1
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Description of Benefits		2005 Small Group POS Plan Options
Description of Benefits		200	2000SX	2001SX	2002SX	2003SX

Lifetime Maximum	In-Network	Unlimited	Unlimited	Unlimited	Unlimited	Unlimited
Lifetime Maximum	Out-of-Network	$5,000,000	$5,000,000	$5,000,000	$5,000,000	$5,000,000

Calendar year Deductible (per member-max 3 members)	In-Network	$0	$0	$0	$500	$1,000
Calendar year Deductible (per member-max 3 members)	Out-of-Network	$300	$300	$500	$1,000	$1,000

Coinsurance	In-Network	100%	100%	100%	100%	100%
Coinsurance	Out-of-Network	70%	70%	60%	60%	60%

Out-of-Pocket Maximum for Calendar Year - Includes Deductible (per member-max 3 members)	In-Network	$0	$0	$0	$500	$1,000
	Out-of-Network	$1,800	$1,800	$4,500	$5,000	$5,000

Physicians Office Visit PCP/Specialist (includes x-ray and lab work done and billed by Drs. office)	In-Network	$15/$20	$25/$25	$25/$25	$25/$25	$40/$40
	Out-of-Network Plan pays after deductible	70%	70%	60%	60%	60%

Outpatient Diagnostic X-ray/Lab (Plan pays after deductible)	In-Network	100%	100%	100%	100%	100%
	Out-of-Network	70%	70%	60%	60%	60%

Outpatient Surgery Facility includes x-ray and lab (Plan pays after deductible)	In-Network	$100 Copay	$100 Copay	$100 Copay	$100 Copay	$100 Copay
	Out-of-Network	70%	70%	60%	60%	60%

Physician Outpatient Services (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	In-Network	100%	100%	100%	100%	100%
	Out-of-Network	70%	70%	60%	60%	60%

Maternity (physician fee only)	In-Network (1st visit only)	$20	$25	$100	$100	$100
Maternity (physician fee only)	Out-of-Network Plan pays after deductible	70%	70%	60%	60%	60%

Inpatient Hospital (Plan pays after deductible)	In-Network	100%	100%	100%	100%	100%
Inpatient Hospital (Plan pays after deductible)	Out-of-Network	70%	70%	60%	60%	60%

Physician Inpatient Services (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	In-Network	100%	100%	100%	100%	100%
	Out-of-Network	70%	70%	60%	60%	60%

Physical and Occupational Therapy, Chiropractic, Athletic Trainers (Plan pays after deductible)	In-Network	$20	$25	$25	$25	$40
	Out-of-Network	70%	70%	60%	60%	60%
	Visits per year	20	20	20	20	20

Inpatient Behavioral Health/Substance Abuse 30 Day calendar year max (Plan pays after deductible)	In-Network	100%	100%	100%	100%	100%
	Out-of-Network	60%	60%	60%	60%	60%

Outpatient Behavioral Health/Substance Abuse 20 Visit calendar year max	In-Network	$25	$25	$25	$25	$40
	Out-of-Network Plan pays after deductible	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered

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

Prescription Drug Copays	Prescription deductible per member (calendar yr)	$0	$0	$0	$0	$0
	Generic/Formulary	$10	$20	$20	$20	$20
	Brand/Formulary	$20	$35	$35	$35	$35
	Non-Formulary	Not Covered	$60	$60	$60	$60
	Mail Order	$40	$60	$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