Small Group Plan Designs

OPEN ACCESS POS
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 BlueCross BlueShield of Georgia

Description of Benefits

Small Group Open Access POS Plan Options
2008AX 2011AX 2507AX 2510AX 2009AX 2508AX
Lifetime Maximum  In-Network Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited
Out-of-Network  $5,000,000  $5,000,000  $5,000,000  $5,000,000  $5,000,000  $5,000,000
Calendar year Deductible
(per member-max 3 members)		  In-Network $1,000 $2,000 $1,000 $2,000 $1,500 $1,500
Out-of-Network $1,000 $4,000 $1,000 $4,000 $1,500 $1,500
Coinsurance  In-Network 100% 100% 80% 80% 100% 80%
Out-of-Network 60% 60% 60% 60% 60% 60%
Out-of-Pocket Maximum for Calendar Year - Includes Deductible
(per member-max 3 members)		  In-Network $0 $0 $1,000 $2,000 $0 $1,000
Out-of-Network $4,000 $4,000 $4,000 $4,000 $4,000 $4,000
Physicians Office Visit PCP/Specialist
(includes x-ray and lab work done and billed by Drs. office)		  In-Network $40/$50 $25/$35 $40/$50 $25/$35  $40/$50  $40/$50
Out-of-Network
Plan pays after deductible		 60% 60% 60% 60% 60% 60%
Outpatient Diagnostic X-ray/Lab
(Plan pays after deductible)		  In-Network 100% 100% 80% 80%  100%  80%
Out-of-Network 60% 60% 60% 60%  60%  60%
Outpatient Surgery Facility includes x-ray and lab
(Plan pays after deductible)		  In-Network $100 Copay; 100% 100% 80% 80%  $100 Copay; 100%  80%
Out-of-Network 60% 60% 60% 60%  60%  60%
Physician Outpatient Services (surgeon, radiologist, anesthesiologist, etc)
(Plan pays after deductible)		  In-Network 100% 100% 100% 80%  100% 100%
Out-of-Network 60% 60% 60% 60%  60% 60%
Maternity
(physician fee only)		  In-Network
(1st visit only)		 $100 $100 $100 $100  $100 $100
Out-of-Network
Plan pays after deductible		 60% 60% 60% 60%  60% 60%
Inpatient Hospital
(Plan pays after deductible)		  In-Network 100% 100% 80% 80% 100% 80%
Out-of-Network 60% 60% 60% 60%  60% 60%
Physician Inpatient Services (surgeon, radiologist, anesthesiologist, etc)
(Plan pays after deductible)		  In-Network 100% 100% 100% 80%  100% 100%
Out-of-Network 60% 60% 60% 60% 60% 60%
Physical and Occupational Therapy,
Chiropractic, Athletic Trainers
(Plan pays after deductible)		  In-Network $50 $35 $50 $35 $50 $50
Out-of-Network 60% 60% 60% 60% 60% 60%
Visits per year 20 20 20 20 20 20
Inpatient Behavioral Health/Substance Abuse
30 Day calendar year max
(Plan pays after deductible)		  In-Network 100% 100% 80% 80% 100% 80%
Out-of-Network 60% 60% 60% 60% 60% 60%
Outpatient Behavioral Health/Substance Abuse
20 Visit calendar year max		  In-Network $50  $35 $50 $35 $50 $50
Out-of-Network
Plan pays after deductible		 Not Covered Not Covered Not Covered  Not Covered   Not Covered  Not Covered

Emergency Room Copay
(waived if admitted)

 In or Out
of Network		 $100 $100 $100 $100  $100 $100
Prescription Drug
Copays

Prescription deductible per member (calendar yr)

 $0 $0 $0 $0  $0 $0

Generic/Formulary

 $20 $15 $20 $15 $20 $20

Brand/Formulary

 $35 $30 $35 $30 $35 $35

Non-Formulary

 $60 $60 $60 $60 $60 $60

Mail Order

 $60/$60 $30$60 $60/$60 $30$60 $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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