Blue Cross HMO Insurance Plans in Georgia

Small Group Plan Designs

HMO
Page 3
click here to see page 2 of options
click here to return to page 1

Description of Benefits		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.

Click here for Blue Cross Group PPO plans Click here for Blue Cross Group POS plans Click here for Blue Cross Open Access POS Click here for page 1 of Blue Cross HMO plans		Click here for Blue Cross Open Access HMO 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!!

9 Dunwoody Park, Suite 136
Atlanta, GA 30338

Call Bob or Holly at
(770) 396-9517
Outside of the Atlanta area, call toll-free:
1-877-711-8376.
Email: holly@insurance-now.com