| |
|
BCBSGa Value PPO Benefit Summary In-Network |
Copays are a first dollar Benefit and are not subject to the Deductible;
all other Benefits are subject to the Deductible unless stated otherwise. |
All Benefits & Deductibles are per person, per calendar year, unless stated otherwise.
|
| Benefits at a Glance |
|
|
|
| |
|
Value 2000 |
Value 3000 |
Value 3500 |
Value 5000 |
Value 10000 |
|
|
In-Network Coverage |
|
|
|
|
|
|
|
Office Visit1 |
|
|
|
|
|
|
|
Primary Doctor |
$40 Copay2 |
$40 Copay2 |
$40 Copay2 |
$40 Copay2 |
$40 Copay2 |
|
|
Specialist |
$40 Copay2 |
$40 Copay2 |
$40 Copay2 |
$40 Copay2 |
$40 Copay2 |
|
|
Preventative Care Adults |
30% coinsurance no deductible. |
|
|
Preventative Care Children |
30% coinsurance no deductible through age 5. |
|
|
Emergency Room |
$150 Copay |
$150 Copay |
$150 Copay |
$150 Copay |
$150 Copay |
|
|
Prescription Drugs |
|
|
|
|
|
|
| |
Rx Deductible |
$200 |
$300 |
$350 |
$500 |
$1,000 |
|
|
Generic |
$15 Copay |
No deductible
$15 Copay |
$15 Copay |
$15 Copay |
$15 Copay |
|
|
Brand |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
|
|
Non-Formulary |
$45 Copay |
$45 Copay |
$45 Copay |
$45 Copay |
$45 Copay |
|
| |
Calendar Year Max Rx Benefit |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
|
|
Deductible |
$2,000 |
$3,000 |
$3,500 |
$5,000 |
$10,000 |
|
|
Coinsurance |
70% / 30% |
70% / 30% |
70% / 30% |
70% / 30% |
70% / 30% |
|
|
Coinsurance Limit |
$2,000 |
$2,000 |
$2,000 |
$2,000 |
$5,000 |
|
|
Out-of-Pocket Limit |
$4,000
|
$5,000
|
$5,500
|
$7,000 |
$15,000
|
|
|
deductible + coinsurance |
|
|
Lifetime Maximum |
$5,000,000 |
$5,000,000 |
$5,000,000 |
$5,000,000 |
$5,000,000 |
|
| |
Hospitalization |
30% Coinsurance
after deductible
|
30% Coinsurance
after deductible
|
30% Coinsurance
after deductible
|
30% Coinsurance
after deductible |
30% Coinsurance
after deductible |
|
|
Surgery |
|
|
Lab / X-Ray |
|
|
Maternity3 |
30% Coinsurance3
after deductible |
$3,000 Copay3 |
Not Covered |
Not Covered |
Not Covered |
|
| |
Pre-Existing Conditions4 |
12 month waiting period |
|
|
Rate Guarantee |
|
|
|
|
|
|
| |
|
9-12 months |
9-12 months |
9-12 months |
9-12 months |
9-12 months |
|
|
Renewal Years |
1 year |
1 year |
1 year |
1 year |
1 year |
|
| |
|
A |
A |
A |
A |
A |
|
| |
Price Stability Rating |
C |
C |
C |
C |
C |
|
| |
1 Office Visit Copays include charges for x-rays and labs when performed and billed by the doctor's office.
2 Office Visit Copays are for the first 6 visits per person per year, combined Primary Doctor and Specialist.
7th and subsequent visits are subject to calendar year deductible and coinsurance.
3 Maternity is included on Family Contracts Only. No maternity benefits are payable for the first 12 months of coverage.
4 A pre-existing condition is an illness, injury or other condition for which medical advice, diagnosis, care or treatment
was recommended or received in the 12 months prior to the effective date of this policy.
No coverage will be provided for the treatment of a pre-existing condition during the first 12 months of this policy.
Preventative Care Adults - Includes state mandated coverages plus an additional $250 benefit. |
Out-of-Network benefits will be less. This is an outline of coverage only.
Please see full plan brochure including exclusions and limitations before applying. |
|
|
