Georgia Blue Cross Blue Shield Health Insurance Plans

2005 Small Group Plan Designs

POS
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Description of Benefits		2005 Small Group POS Plan Options
Description of Benefits		2503SX	2504SX	2800SX	2801SX

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

Calendar year Deductible (per member-max 3 members)	In-Network	$1,500	$1,000	$1,000	$2,000
Calendar year Deductible (per member-max 3 members)	Out-of-Network	$1,500	$3,000	$3,000	$4,000

Coinsurance	In-Network	80%	80%	70%	70%
Coinsurance	Out-of-Network	60%	60%	60%	60%

Out-of-Pocket Maximum for Calendar Year - Includes Deductible (per member-max 3 members)	In-Network	$2,500	$4,000	$4,000	$5,000
	Out-of-Network	$5,500	$18,000	$18,000	$12,000

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	$40/$40
	Out-of-Network Plan pays after deductible	60%	60%	60%	60%

Outpatient Diagnostic X-ray/Lab (Plan pays after deductible)	In-Network	80%	80%	70%	70%
	Out-of-Network	60%	60%	60%	60%

Outpatient Surgery Facility includes x-ray and lab (Plan pays after deductible)	In-Network	80%	$500 Copay per adm; 80%	$500 Copay per adm; 70%	$1,000 Copay per adm; 70%
	Out-of-Network	60%	60%	60%	60%

Physician Outpatient Services (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	In-Network	100%	80%	70%	70%
	Out-of-Network	60%	60%	60%	60%

Maternity (physician fee only)	In-Network (1st visit only)	$100	$500	$500	$1,000
Maternity (physician fee only)	Out-of-Network Plan pays after deductible	60%	60%	60%	60%

Inpatient Hospital (Plan pays after deductible)	In-Network	80%	$500 Copay per adm; 80%	$500 Copay per adm; 70%	$1,000 Copay per adm; 70%
Inpatient Hospital (Plan pays after deductible)	Out-of-Network	60%	60%	60%	60%

Physician Inpatient Services (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	In-Network	100%	80%	70%	70%
	Out-of-Network	60%	60%	60%	60%

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

Inpatient Behavioral Health/Substance Abuse 30 Day calendar year max (Plan pays after deductible)	In-Network	80%	$500 Copay per adm; 80%	$500 Copay per adm; 70%	$1,000 Copay per adm; 70%
	Out-of-Network	60%	60%	60%	60%

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

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

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

Click here for more Blue Cross POS plans and benefits Click here for Blue Cross Group PPO plans and benefits Click here for Blue Cross Group HMO plans and benefits		Click here for Blue Cross Group Dental plans/benefits Click here for Individual Plan Options
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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