Blue Cross and Blue Shield of Georgia Small Group PPO Plans

2005 Small Group Plan Designs

PPO
Page 3
Return to page 1 of PPO Benefit Plan Options

Description of Benefits		2005 Small Group PPO Plan Options
Description of Benefits		1504SX	1505SX	1506SX	1507SX

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

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

Out-of-Pocket Maximum for Calendar Year - Includes Deductible (per member-max 3 members)	In-Network	$3,000	$3,500	$6,000	$3,000
	Out-of-Network	$6,000	$7,000	$18,000	$6,000

Physicians Office Visit PCP/Specialist (includes x-ray and lab work done and billed by Drs. office)	In-Network	$40/$40	$40/$40	$40/$50	$40/$40
	Out-of-Network Plan pays after deductible	60%	60%	60%	$60 Copay

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

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

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%	80%

Inpatient Hospital (Plan pays after deductible)	In-Network	80%	80%	$500 Copay per adm:80%	80%
Inpatient Hospital (Plan pays after deductible)	Out-of-Network	60%	60%	60%	80%

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

Physical and Occupational Therapy, Chiropractic, Athletic Trainers (Plan pays after deductible)	In-Network	80%	80%	80%	80%
	Out-of-Network	60%	60%	60%	80%
	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%	$500 Copay per adm:80%	80%
	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	60%	60%	60%	60%

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

Prescription Drug Copays	Prescription deductible per member (calendar yr)	$0	$0	$250	$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.

Click here for more Blue Cross PPO plans and benefits Click here for Blue Cross Group POS plans and benefits Click here for Blue Cross Group HMO plans and benefits			Click here for Blue Cross Group Dental plans Click here for Individual Plan Options
Call today or click here to download a census form for a quick quote!!

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