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| Description of Benefits |
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| 3501AX | 3503AX | 3802AX | 3801AX | ||
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| Lifetime Maximum | Unlimited | Unlimited | Unlimited | Unlimited | |
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Calendar
year Deductible (per member-max 3 members) |
In-Network | $1,000 | $2,000 | $3,000 | $2,000 |
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| Coinsurance | In-Network | 80% | 80% | 70% | 70% |
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Out-of-Pocket
Maximum for Calendar Year - Includes Deductible (per member-max 3 members) |
In-Network | $2,000 | $2,000 | $3,000 | $2,000 |
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Physicians
Office Visit PCP/Specialist (includes x-ray and lab work done and billed by Drs. office) |
In-Network | $40/$50 | $25/$35 | $25/$35 | $40/$50 |
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Outpatient
Diagnostic X-ray/Lab (Plan pays after deductible) |
In-Network | 100% | 80% | 70% | 70% |
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Outpatient
Surgery Facility
includes
x-ray and lab (Plan pays after deductible) |
In-Network | $500copay; 80% | 80% | 70% | $1000copay; 70% |
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Physician
Outpatient Services (surgeon,
radiologist, anesthesiologist, etc) (Plan pays after deductible) |
In-Network | 80% | 80% | 70% | 70% |
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Maternity (physician fee only) |
In-Network (1st visit only) |
$500 | $100 | $150 | $1,000 |
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Inpatient
Hospital (Plan pays after deductible) |
In-Network | $500 copay per admission; 80% | 80% | 70% | $1,000copay per admission; 70% |
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Physician
Inpatient Services (surgeon,
radiologist, anesthesiologist, etc) (Plan pays after deductible) |
In-Network | 80% | 80% | 70% | 70% |
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Physical
and Occupational Therapy 20 visits allowed per year |
In-Network | $50 | $35 | $35 | $50 |
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Chiropractic
Care 20 visits allowed per year |
In-Network | $15 | $15 | $15 | $15 |
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Inpatient
Behavioral Health/Substance Abuse 30 Day calendar year max (Plan pays after deductible) |
In-Network | $500 copay per admission; 80% | 80% | 70% | $1,000copay per admission; 70% |
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Outpatient
Behavioral Health/Substance Abuse 20 Visit calendar year max |
In-Network |
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Emergency
Room Copay |
In or Out of Network |
$150 | $100 | $150 | $150 |
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Prescription
Drug Copays |
Prescription deductible per member (calendar yr) |
$0 |
$0 |
$0 |
$250 |
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Generic/Formulary |
$20 | $15 | $15 | $20 | |
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Brand/Formulary |
$35 | $30 | $30 | $35 | |
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Non-Formulary |
$60 | $60 | $60 | NOT COVERED | |
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Mail Order |
$60 | $30/$60 | $30/$60 | $30/$60 | |
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| 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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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 Blue Cross Group HMO plans |
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here for more Blue Cross Open Access HMO Click here for Blue Cross Group Dental plans Click here for Individual Plan Options |
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 9 Dunwoody Park, Suite 136 Atlanta, GA 30338 |
(770) 396-9517 Outside of the Atlanta area, call toll-free: 1-877-711-8376. Email: holly@insurance-now.com |
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