FEATURE

PPO PLAN, Georgia In-Network

(BCBSGa)

PPO PLAN,
 National In-Network
(BlueCard)

PPO PLAN, Out-of-Network

Pre-Existing Conditions

None

None

None

Max Lifetime Benefit

$2 million

$2 million

$2 million

Max. Annual Deductible

$300 individual
$900 family

$ 400 individual
$1200 family

$ 400 individual
$1200 family

Max. Annual Out-of-Pocket (Stop-Loss)

$1000 individual
$2000 family

$2000 individual
$4000 family

$2000 individual
$4000 family

Physician Ofc Visit

$100% of network rate after $20 co-payment per visit—applies to ofc visit only (non-surgical svcs).

100% of network rate after $20 co-payment per visit—applies to ofc visit only (non-surgical svcs).

60% of network rate for non-surgical svcs.

Wellness Care/
Preventive Care

$750/ person per plan year paid at 100%; not subject to deductible; $20 co-payment per ofc visit.

$750/ person per plan year paid at 100%; not subject to deductible; $20 co-payment per ofc visit.

Not covered.  Charges do not apply to annual deductible or annual-out of pocket maximum.

Lab Svcs provided in Physician’s Ofc (exclusive of wellness/prev. care

90% of network rate; subject to deductible.

80% of network rate; subject to deductible.

60% of network rate; subject to deductible and balance billing.

Maternity Care (prenatal, delivery, postnatal)

90% of network rate after an initial visit co-payment of $20.

80% of network rate after an initial visit co-payment of $20.

60% of network rate; subject to deductible and balance billing.

Outpatient Surgery

90% of network rate

80% of network rate

60% of network rate; subject to deductible and balance billing.

Second Surgical Opinions

100% of network rate after a $20 co-payment per visit; not subject to deductible.

100% of network rate after a $20 co-payment per visit, not subject to deductible.

60% of network rate; subject to deductible and balance billing.

Allergy Testing

90% of network rate

80% of network rate

60% of network rate; subject to deductible and balance billing.

Allergy Shots & Serum

100% for allergy shots & serum; not subject to deductible.

100% for allergy shots & serum; not subject to deductible.

60% of network rate; subject to deductible and balance billing.

Medical Eye Services

100% of network rate after $20 copay per visit; applies to non-surgical services

100% of network rate after $20 copay per visit; applies to non-surgical services

60% of network rate for nonsurgical services

In-Patient Hospital Physician Care/Surgery

90% of network rate subject to deductible and balance billing

80% of network rate subject to deductible and balance billing

60% of network rate; subject to deductible and balance billing.

Inpatient Hospital Svcs Other than for Emergency Room Care

90% of network rate

80% of network rate

60% of contracted State of Georgia DRG rate; subject to deductible and balance billing.

Maternity Care In-Hospital (Delivery)

90% of contracted DRG rate

80% of network rate

60%of contracted Ga rate; subject to ded. and balance billing.

Inpatient-Hospital Laboratory Svcs

90% of network rate

80% of network rate

60% of contracted State of Georgia DRG rate; subject to deductible and balance billing.

Inpatient Hospice Care

100% of network rate

100% of network rate

60% of network rate; subject to deductible and balance billing.

Surgical Management of Weight Loss

Not Available

Not Available

Not Available

Outpatient Physician Care/Surgery Physician Svcs

90% of network rate

80% of network rate

60% of network rate; subject to deductible and balance billing

Outpatient Facility Selected by Treating Physician

90% of network rate

80% of network rate

60% of network rate; subject to deductible and balance billing.

Care in Hospital Emergency Room

90% of network rate after a $75 co-payment per visit; co-payment is reduced to $50 if referred by 24/7 NurseLine.  Co-payment is waived, if admitted within 24 hrs.

90% of network rate after a $75 co-payment per visit;co-payment is reduced to $50 if referred by 24/7 NurseLine.  Co-payment is waived if admitted within 24 hrs.

90% of network rate after a $75 co-payment per visit; co-payment is reduced to $50 if referred by 24/7 NurseLine. Co-payment is waived if admitted within 24 hrs.

Outpatient
Laboratory Svcs

90% of network rate

80% of network rate

60% of network rate; subject to deductible and balance billing.

Urgent Care Svcs

90% of network rate after $20 co-payment per visit.

80% of network rate after $20 co-payment per visit.

60% of network rate; subject to deductible and balance billing.

Home Nursing Care

90% of network rate; limited to 2 hours of care in a 24-hour day.

80% of network rate; limited to 2 hours of care in a 24-hour day.

60% of network rate; limited to 2 hours of care in a 24-hour day; subject to deductible and balance billing.

Extended Care Facility

Not available

Not available

Not available

Home Hyperalimentation

90% of network rate; lifetime limit of $500,000

80% of network rate
Lifetime limit of $500,000

60% of network rate; subject to deductible and balance billing.

Outpatient Hospice Care

100% of network rate

100% of network rate

60% of network rate; subject to deductible and balance billing.

Cochlear Implants

90% of network rate

80% of network rate

60% of network rate; subject to deductible and balance billing.

Ambulance Svcs

90% of network rate

90% of network rate

90% of network rate; subject to the 1st Medical Network in-network deductible; subject to balance billing.

Durable Medical Equipment

90% of network rate

80% of network rate

60% of network rate; subject to deductible and balance billing.

Outpatient Short Term Rehabilitation Svcs

90% of network rate; Physical, speech, cardiac and occupational therapies are limited to 40 visits per incident type per plan year.

80% of network rate; Physical, speech, cardiac and occupational therapies are limited to 40 visits per incident type per plan year.

60% of network rate; subject to deductible and balance billing; Physical, speech, cardiac, and occupational therapies are limited to 40 visits per incident type per plan year.

Chiropractic Care

90% of network rate; limited to 40 visits per member per plan year.

80% of network rate; limited to 40 visits per member per plan year.

60% of network rate; subject to deductible and balance billing; limited to 40 visits per member per plan year.

Surgical Extraction of Impacted Teeth
(Medical benefits are not available for partially erupted teeth)

90% of network rate

80% of network rate

60% of network rate

Treatment of TMJ

90% of network rate; lifetime benefit limit $1100

80% of network rate; lifetime benefit limit $1100

60% of network rate; lifetime benefit limit $1100

Dental/Oral Care
(Not covered other than accidental injury to natural teeth)

90% of network rate

80% of  network rate

60% of network rate

360 degree Health Programs

Condition Care Programs 1-800-785-0006.

Mental Health/Substance Abuse

Facility Charges for Inpatient In-network: 90% of network rate; subject to deductible and to a separate $100 hospital deductible; maximum benefit of 60 combined mental health and substance abuse days per person per plan year; substance abuse coverage limited to 3 episodes per lifetime.

Provider Charges for Inpatient In-Network: 80% of network rate; maximum of 60 visits per person per plan year.  For outpatient: 80% of network rate with auth. from BCBSGa.

Facility Charges for Inpatient In-Network: 90% of network rate; subject to deductible and to a separate $100 hospital deductible; maximum benefits of 60 combined mental health and substance abuse days per person per plan year; substance abuse coverage limited to 3 episodes per lifetime.

Provider Charges for Inpatient In-Network:  80% of network rate; maximum of 60 visits per person per plan year.  For outpatient: 80% of network rate with authorization from BCBSGa.

Not applicable.