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


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Description of Benefits

Premier POS

Premier PPO
Lifetime Maximum Per Member

Unlimited

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

Individual

$750

$1,500

$2,500
 $3,500

$750

$1,500

$2,500

 $3,500

 $5,000

 $7,500

 $10,000
  $20,000

 $5,000

 $7,500

 $10,000

 $20,000

Family (the maximum amount of deductible per year for everyone combined)

$1,500

$3,000

$5,000

 $7,000

$1,500

$3,000

$5,000

 $7,000

$10,000

$15,000

$20,000

 $40,000

$10,000

$15,000

$20,000

 $40,000
Calendar Year
Out-of-Pocket
Maximum		 Individual

Your deductible plus $2,500*

Your deductible plus $3,000
Family (the maximum amount out of pocket per year for everyone combined)

Your deductible plus $5,000*

Your deductible plus $6,000

*If you choose the $7,500, the $10,000 or $20,000 individual 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 POS Premier PPO
Preventive Care Member Pays $0  Member Pays $0
Doctor's Office Visits (PCP / Specialist)
Unlimited # of Visits Per Year

$35 / $50 Copayment
Not subject to deductible

$35 / $50 Copayment
Not subject to deductible
Professional Services
(x-ray, lab, anesthesia, surgeon,
diagnostics, etc.)

Member pays 20% after
annual deductible (0% with $7,500
$10,000 or $20,000 deductible)

Member pays 20% after
annual deductible (0% with $7,500
$10,000 or $20,000 deductible)
Hospital Inpatient
(overnight hospital stays)

Member pays 20% after
annual deductible (0% with $7,500
$10,000 or $20,000 deductible)

Member pays 20% after
annual deductible (0% with $7,500
$10,000 or $20,000 deductible)
Hospital Outpatient
(if you don't stay overnight)

Member pays 20% after
annual deductible (0% with $7,500
$10,000 or $20,000 deductible)

Member pays 20% after
annual deductible (0% with $7,500
$10,000 or $20,000 deductible)
Emergency Room Care
(Accidental injury or Medical Emergency
as defined by BCBSGa)

Member pays 20% after
annual deductible (0% with $7,500
$10,000 or $20,000 deductible)

Member pays 20% after
annual deductible (0% with $7,500
$10,000 or $20,000 deductible)
Maternity

Available at Additional Cost on Premier Plans with $2,500 Deductible and Above

Available at Additional Cost on Premier Plans with $2,500 Deductible and Above
Dental

Optional coverage available

Optional coverage available
Life

Optional coverage available

Optional coverage available
Prescription Drug Coverage Premier POS Premier PPO
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

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" group 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.
An online application and a printable application option is now available
  Click here to request that an enrollment package be emailed or mailed to you  

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Outside of the Atlanta area,
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