BLUE CHOICE HEALTH PLAN 
HEALTH MAINTENANCE ORGANIZATION (HMO)

Members in this plan must use the Blue Choice HMO network providers.  The closest participating primary care physicians to Carrollton currently are in Villa Rica.  This is an in-network benefit level plan; there is no coverage for out-of-network in the Blue Choice HMO Plan. Participants must declare a primary care physician from the HMO network at the time of enrollment.   On-line provider directory information can be obtained at www.bcbsga.com (Blue Choice HMO network), or by calling their customer service line at 1-800-424-8950.

                                                    BLUE CHOICE (HMO)


PLAN DESIGN FEATURES

 

Max. Lifetime Benefit

$2 million

Annual Medical Deductible

None

Annual Pharmacy Deductible

None

Maximum Annual Out-of-Pocket (Stop Loss)

Individual-No annual maximum
Family-No annual maximum

Pre-Existing Conditions

None

PHYSICIAN SERVICES IN OFFICE SETTING

COPAYS

Office Visits:  Wellness/Preventive Care

 

   Well-child care, immunization

$15 Copayment

   Physical Examinations

$15 Copayment

   Annual gynecology examination (No PCP referral
   Required-Must use network provider)    

$15 Copayment

  Routine Eye Exams

Not Covered

  Routine Hearing Exams

Not Covered

Illness or Injury

 

   Primary Care Physician (PSP) office visit includes
 
  lab, radiology and office surgery)

$15 Copayment

   Specialty care physician office visit (PCP referral
   Required)

$15 Copayment

   Second Surgical Opinion (PCP referral required)

$15 Copayment

   Maternity Services (prenatal, delivery and post-
   partum

All related physician care services are covered by $15 copayment at first office visit

   Allergy care (primary care physician office visit,
   Specialty care, allergy shots, serum and testing)

$15 Copayment

   Vision care services provided by network        
   Ophthalmologist or optometrist for the treatment
   Of acute conditions (No PCP referral required)

$15 Copayment

   Services provided by a network dermatologist
   (No PCP referral required)

$15 Copayment

Dental Care

Not covered except for accidental injury to natural teeth or extraction of impacted teeth.

EMERGENCY ROOM SERVICES

 

   Life Threatening illness, serious accidental
   Injury or with a PCP referral

$75 Copayment; waived if admitted

   Non-emergency use of the emergency room

Not covered

INPATIENT HOSPITAL SERVICES

COPAYS

   Daily room, board and general nursing care at 
   Semi-private room rate, ICU/CCU charges;
   Other medically necessary hospital charges such
   Diagnostic x-ray and lab services; newborn
   Nursery care.

Plan pays 100% after a $200 copay

   Physician Services (surgery, anesthesia, radiology,
   pathology, etc.) 

Plan pays 100% after a $200 copay

OUTPATIENT SERVICES

In-Network Benefits Level (no coverage for out-of network)

   Facility/hospital charges (including diagnostic
   x-ray and lab services)

Play pays 100%

   Physician Services (surgery, anesthesia, radiology,
   Pathology, etc)

Plan pays 100%, after a $50 copay

   Therapy Services
      -Speech Therapy
      -Physical, Occupational Therapy
      -Respiratory Therapy
      -Radiation Therapy, Chemotherapy
      -Chiropractic Care (No referral required)

$15 Copayment; 30-vist calendar year maximum
$15 Copayment; 40 visit calendar year maximum
Plan pays 100%; 40 visit calendar year maximum
Plan pays 100%
$15 Copayment; 20 visit calendar year maximum

Behavioral Health/Substance Abuse Services

No PCP referral required.  Services must be  authorized by BCBSGa Behavioral Health at
1-800-292-2879.

   Inpatient (facility and physician fee)

Plan pays 100% after a $200 copay; 30-day calendar year maximum

   Outpatient

$25 copayment; 20-visit calendar year maximum

   Inpatient alcohol substance abuse detoxification

Plan pays 100%; 6-day calendar year maximum (combined with other inpatient behavioral health and substance abuse benefits)

OTHER SERVICES

 

   Skilled Nursing Facility

Plan pays 100%; 30-day calendar year maximum

   Home Health Care

Plan pays 100%; 120-visit calendar year maximum

   Hospice Care

Plan pays 100%; $10,000 lifetime maximum

   Ambulance

Plan pays 100% when medically necessary

PRESCRIPTION DRUGS

Prescription must be written by a network physician or an emergency room physician

Blue Choice participating pharmacies include: CVS,
Eckerd, Kmart, Kroger, Publix, Walgreens,
Wal-Mart, and many independent pharmacies

$10  Co-payment for Generic (up to 30 day supply)
$25  Co-payment for Name Brand (up to 30 day
        Supply)



CONSUMER CHOICE OPTION:
If you select the Consumer Choice Option for the PPO or HMO plans, and your personal physician or hospital is not a member of the respective PPO or HMO networks, the Georgia Consumer Choice statute permits you to nominate a provider to render medical care at in-network levels of benefit coverage. A physician or hospital must have the appropriate licensing; must agree to the PPO’s or HMO’s contractual terms and conditions for network providers; and must accept the plan’s reimbursement rates. However, a physician or a hospital that has been nominated by a member may decline to participate in the PPO or HMO network. If you select a Consumer Choice option, you will be required to continue under that healthcare plan choice for the remainder of the plan year. While the premium for Consumer Choice is higher, the benefit will be identical to the in-network coverage.

 

 MONTHLY PREMIUMS – PLAN YEAR 2009

 

PLAN

 

EMPLOYEE ONLY

 

EMPLOYEE + CHILD

 

EMPLOYEE + SPOUSE

 

SELF + FAMILY

BOR Traditional Indemnity Plan

 

 

$ 302.00

 

$ 543.46

 

$ 634.08

 

$ 875.62

BOR Preferred Provider Organization (PPO)

 

$ 135.66

 

$ 244.18

 

$ 284.88

 

$ 393.40

BOR Preferred Provider Organization (PPO)
Consumer Choice *

 

$ 180.90

 

$ 325.62

 

$ 379.86

 

$ 524.54

 

Blue Choice HMO

 

$ 100.68

 

$ 181.22

 

$ 211.42

 

$ 291.98

Blue Choice HMO*
Consumer Choice

 

             $ 159.42

 

$ 286.92

 

$ 334.76

 

$ 462.30

 

Kaiser Permanente HMO

 

$ 104.14

 

$ 187.48

 

$ 218.72

 

 $ 302.04

 

Kaiser Permanente HMO Consumer Choice*

 

$ 164.92

 

$ 296.82

 

$ 346.26

 

$ 478.22

 

High Deductible Health Plan/HSA (HDHP/HSA)

 

$ 23.84

 

$ 41.66

 

$ 48.34

 

$ 66.16

 

High Deductible Health Plan/HSA (HDHP/HSA)
Consumer Choice*

 

$ 47.68

 

$ 83.30

 

$ 96.66

 

$ 132.30

*Consumer Choice Option:  This coverage allows you to nominate an out-of-network provider to function as an in-network provider for you, subject to plan and provider approval.  This election is irrevocable during the plan year.