Blue Cross Georgia PPO Small Group Insurance Benefits

2005 Small Group Plan Designs

PPO
Page 2
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Description of Benefits		2005 Small Group PPO Plan Options
Description of Benefits		1500SX	1501SX	1502SX	1503SX

Lifetime Maximum (in and out-of-network combined)		$5,000,000	$5,000,000	$5,000,000	$5,000,000

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

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

Out-of-Pocket Maximum for Calendar Year - Includes Deductible (per member-max 3 members)	In-Network	$1,500	$2,000	$2,500	$2,500
	Out-of-Network	$3,000	$4,000	$5,000	$5,000

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

Outpatient Surgery Facility includes x-ray and lab (Plan pays after deductible)	In-Network	80%	80%	80%	80%
	Out-of-Network	60%	60%	60%	60%

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

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

Inpatient Hospital (Plan pays after deductible)	In-Network	80%	80%	80%	80%
Inpatient Hospital (Plan pays after deductible)	Out-of-Network	60%	70%	60%	60%

Physician Inpatient Services (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	In-Network	80%	90%	80%	80%
	Out-of-Network	60%	70%	60%	60%

Physical and Occupational Therapy, Chiropractic, Athletic Trainers (Plan pays after deductible)	In-Network	80%	80%	80%	80%
	Out-of-Network	60%	70%	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%	80%	80%	80%
	Out-of-Network	60%	60%	60%	60%

Outpatient Behavioral Health/Substance Abuse 20 Visit calendar year max	In-Network	$25	$40	$40	$25
	Out-of-Network Plan pays after deductible	60%	60%	60%	60%

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

Prescription Drug Copays	Prescription deductible per member (calendar yr)	$0	$0	$0	$0
	Generic/Formulary	$20	$20	$20	$20
	Brand/Formulary	$35	$35	$35	$35
	Non-Formulary	$60	$60	$60	$60
	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.

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