Blue Cross Blue Shield of Georgia Premier
and Smart Sense PPO In-Network Benefit Summary*


An online application and a printable application option are now available

Description of Benefits

Premier Plus POS

Premier Plus PPO
Lifetime Maximum Per Member

Unlimited

Unlimited
Calendar Year
Deductible Choices
(Separate deductibles apply for in-netowks and out-of-network		 Individual

$750

$1,500

$2,500

$750

$1,500

$2,500
Family

$5,000

$10,000

$20,000

$750

$10,000

$20,000
Calendar Year
Out-of-Pocket
Maximum

Individual

Your deductible plus $2,500*

Your deductible plus $3,000

Family

Your deductible plus $5,000*

Your deductible plus $6,000

*For Premier plan, if you choose the $10,000 or $20,000 individual deductible or the $20,000 or $40,000 family deductible, your Calendar year out-of-pocket maximum is your deductible only
Covered Services
These amounts show your share
of costs after deductible, if any.

Premier
  SmartSense
Child Preventive Care
(Through age 5)

$35 Copayment
Not subject to deductible

$30 copayment for the first
3 visits per member per year
not subject to deductible.

After 3 visits, once deductible
is met, then 30%
Preventive Care (age 6 and over)
(Services such as PSA test, Colorectal screening, mammograms, pap test,
flu shot and colonoscopy. Premier also
covers annual physical exam)

$35 Copayment
Not subject to deductible

$30 copayment for the first
3 visits per member per year
not subject to deductible.

After 3 visits, once deductible
is met, then 30%
Doctor's Office Visits

$35 Copayment
Not subject to deductible

$30 copayment for the first
3 visits per member per year
not subject to deductible.

After 3 visits, once deductible
is met, then 30%
Professional Services
(x-ray, lab, anesthesia, surgeon,
diagnostics, etc.)

Member pays 20% after
annual deductible (0% with
$10,000 or $20,000 deductible)

Member pays 30% after
annual deductible
Hospital Inpatient
(overnight hospital stays)

Member pays 20% after
annual deductible (0% with
$10,000 or $20,000 deductible)

Member pays 30% after
annual deductible
Hospital Outpatient
(if you don't stay overnight)

Member pays 20% after
annual deductible (0% with
$10,000 or $20,000 deductible)

Member pays 30% after
annual deductible
Emergency Room Care
(Accidental injury or Medical Emergency
as defined by BCBSGa)

Member pays 20% after
annual deductible (0% with
$10,000 or $20,000 deductible)

Member pays 30% after
annual deductible
Maternity

Optional coverage available for $144

Not covered
Dental

Optional coverage available

Optional coverage available
Life

Optional coverage available

Optional coverage available
Vision

$10 Exam - Discount on eyewear

Not Available
Prescription Drug
Coverage

Premier

SmartSense
Generic Prescription Drug Coverage

$15 copay
(or 40%, whichever is greater) Not subject to deductible

$15 copay
(or 40%, whichever is greater) Not subject to deductible
Comprehensive (Specialty and Brand name) Prescription Drug Coverage

Separate $250 calendar year deductible for brand name or specialty drugs
$15 copay or 40% (whichever is greater) plus the difference in allowable charge if Brand is chosen over available generic.

Out of pocket maximum $300 per prescription and $4000 per person per calendar year

Not Covered
Optional Coverage Available - Separate $250 calendar year deductible for brand name or specialty drugs
$15 copay or 40% (whichever is greater) plus the difference in allowable charge if Brand is chosen over available generic.

Out of pocket maximum $300 per prescription and $4000 per person per calendar year

Waiting period for pre-existing conditions is 12 months from contract effective date. If you apply within 63 days of terminating your membership with another "creditable" health care plan, then you can use your prior coverage credit toward the 12 month waiting period.
*Refer to your individual certificate of coverage for complete benefit details
including a full list of exclusions and limitations.
  Click here to request an enrollment kit

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(770) 396-9517
Outside of the Atlanta area,
call toll-free:
1-877-711-8376.
Email: holly@insurance-now.com