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PPO and POS In-Network Benefit Summary An online application and a printable application option is now available |
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Lifetime Maximum Per Member |
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Calendar
Year Deductible Choices (Separate deductibles apply for in-network and out-of-network) |
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$3,500 |
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$20,000 |
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Calendar
Year Out-of-Pocket Maximum |
Individual |
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Family (the maximum amount out of pocket per year for everyone combined) |
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Covered Services These amounts show your share of costs after deductible, if any. |
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Preventive Care | Member Pays $0 | Member Pays $0 | ||||||||
Doctor's
Office Visits (PCP
/ Specialist) Unlimited # of Visits Per Year |
Not subject to deductible |
Not subject to deductible |
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Professional
Services (x-ray, lab, anesthesia, surgeon, diagnostics, etc.) |
annual deductible (0% with $7,500 $10,000 or $20,000 deductible) |
annual deductible (0% with $7,500 $10,000 or $20,000 deductible) |
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Hospital
Inpatient (overnight hospital stays) |
annual deductible (0% with $7,500 $10,000 or $20,000 deductible) |
annual deductible (0% with $7,500 $10,000 or $20,000 deductible) |
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Hospital
Outpatient (if you don't stay overnight) |
annual deductible (0% with $7,500 $10,000 or $20,000 deductible) |
annual deductible (0% with $7,500 $10,000 or $20,000 deductible) |
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Emergency
Room Care (Accidental injury or Medical Emergency as defined by BCBSGa) |
annual deductible (0% with $7,500 $10,000 or $20,000 deductible) |
annual deductible (0% with $7,500 $10,000 or $20,000 deductible) |
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Maternity |
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Dental |
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Life |
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Prescription Drug Coverage |
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There is a $2,500 Out-of-Pocket Maximum Per Person Per Year,
then Plan Pays at 100% Prescription Copays are based on a 30 day supply |
Tier 1 (most
generic drugs)* - $15 Copay Tier 2 (most preferred brand drugs)* - $30 Copay Tier 3 (most non-preferred drugs) *- $60 Copay Tier 4 (most specialty and injectibles)-25% of cost *If a brand name drug is chosen when a generic is available, member pays the copya PLUS cost difference |
Tier 1 (most
generic drugs)* - $15 Copay Tier 2 (most preferred brand drugs)* - $30 Copay Tier 3 (most non-preferred drugs) *- $60 Copay Tier 4 (most specialty and injectibles)-25% of cost *If a brand name drug is chosen when a generic is available, member pays the copya PLUS cost difference |
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*Refer to your individual certificate of coverage for complete benefit details including a full list of exclusions and limitations. An online application and a printable application option is now available Insurance Now and it's agents are independent authorized agents representing Blue Cross and Blue Shield of Georgia* *Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc., are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. |
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Click here to request that an enrollment package be emailed or mailed to you |
![]() 5 Dunwoody Park South Suite 113 Atlanta, GA 30338 |
(770) 396-9517 Outside of the Atlanta area, call toll-free: 1-877-711-8376. Email: holly@insurance-now.com |
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