Key Benefits In-Network Out-of-Network Covered Services In ...

BlueChoice PPO (HRA)Large Group (51+ Employees)9805SX- All benefits, including Pharmacy, are subject to the deductible unless otherwise stated.- Members are responsible for deductibles as described below.- Members are also responsible for all costs over the plan maximums.- When using Out-of-Network providers, members may be responsible for any differencebetween the allowed amount and actual charges, as well as any deductibles.Key Benefits In-Network Out-of-NetworkLifetime Maximum $5,000,000Combined for INN and OON.Calendar Year Deductible- Individual (single coverage) $1,250- Family (two or more individuals) $2,500Combined for INN and OON.For a family contract, all eligible members share acombined family deductible.Coinsurance Plan pays 80% Plan pays 60%after deductibleafter deductibleOut-of-Pocket Calendar Year Maximum- Individual $5,000 $10,000- Family $10,000 $20,000Includes the Calendar Year Deductible.INN and OON amounts remain separate - they do not cross accumulate.Covered Services In-Network Out-of-NetworkPreventive CareAdult and child Plan pays 100% (not Plan pays 70% (deductiblesubject to deductible) waived through age 5)Illness or InjuryPreferred physician office visit Plan pays 80% Plan pays 60%Includes diagnostic X-ray and lab servicesperformed in physician's officeSurgery in physician's office Plan pays 80% Plan pays 60%Allergy care Plan pays 80% Plan pays 60%Includes testing, serum, and shotsMaternity physician services Plan pays 80% Plan pays 60%Includes prenatal, delivery, postpartumEmergency Room ServicesLife-threatening illness or serious accidental injury Plan pays 80% Plan pays 80%Non-emergency use Plan pays 80% Plan pays 60%Hospital Inpatient Services - Pre-Authorization Certification is RequiredDaily room, board and general nursing care at Plan pays 80% Plan pays 60%semi-private room rate- ICU / CCU charges- Newborn nursery care- Other medically necessary hospital chargessuch as diagnostic X-ray and lab servicesPhysician Plan pays 80% Plan pays 60%Surgeon, anesthesiologist, radiologist, pathologist

BlueChoice PPO (HRA)9805SXCovered Services In-Network Out-of-NetworkOutpatient ServicesFacility / hospital charges Plan pays 80% Plan pays 60%Including diagnostic X-ray and lab servicesPhysician Plan pays 80% Plan pays 60%Surgeon, anesthesiologist, radiologist, pathologistTherapy ServicesPhysical, occupational, chiropractic care, athletic trainers Plan pays 80% Plan pays 60%Visits per calendar year, combined specialties20 visitsVisits combined for INN and OONRespiratory therapy Plan pays 80% Plan pays 60%Visits per calendar year30 visitsVisits combined for INN and OONSpeech therapy Plan pays 80% Plan pays 60%Visits per calendar year20 visitsVisits combined for INN and OONRadiation therapy and chemotherapy Plan pays 80% Plan pays 60%Mental Health / Substance AbuseInpatient Plan pays 80% Plan pays 60%Outpatient Plan pays 80% Plan pays 60%Other ServicesAmbulance Plan pays 80% Plan pays 60%When medically necessaryHome health care Plan pays 80% Plan pays 60%Visits per calendar year120 visitsVisits combined for INN and OONHospice care Plan pays 100% Plan pays 100%$10,000 lifetime maximumSkilled nursing facility Plan pays 80% Plan pays 60%Days per calendar year30 daysDays combined for INN and OONPharmacyPrescription Drugs Plan pays 80% Plan pays 80%Unless otherwise indicated in the Certificate Booklet, each prescription has a 30-day supply limit.Members must file a claim for reimbursement when using an Out-of-Network pharmacy.For a full disclosure of all benefits, exclusions and limitations, refer to the Certificate Booklet.

Pre-Existing Condition Limitation and Credit for Prior CoverageUntil a member has had “creditable coverage” for 12 consecutive months, benefits for serviceshall not be available for any illness, injury or condition for which medical advice ortreatment was recommended by, or received from, a health care provider within sixmonths preceding the effective date of coverage (except maternity services, for whichthe pre-existing condition limitation is not applicable).Summary of Limitations and ExclusionsYour Certificate Booklet will provide you with complete benefit coverage information.Some key limitations and exclusions, however, are listed below:- Care or treatment that is not medically necessary- Cosmetic surgery, except to restore function altered by disease or trauma- Dental care and oral surgery; except for accidental injury to natural teethand limited treatment of TMJ.- Occupational related illness or injury- Routine physical examinations necessitated by employment, foreign travelor participation in school athletic programs- Smoking cessation products- Surgical or medical care for: artificial insemination, in-vitro fertilization,reversal of voluntary sterilization, radial keratotomy, learning disabilities,mental retardation, hyperkinetic syndrome or autistic disease of childhood- Treatment, drugs or supplies considered experimental or investigationalBlueCard ProgramBlueCard is a network partnership with all Blue Cross Blue Shield plans across thecountry. Through this cooperative arrangement, you receive participating providerdiscounts and more efficient processing of medical claims. This partnership also createsthe largest provider network in the U.S.See Certificate Booklet for Complete DetailsIt is important to keep in mind that this material is a brief outlineof benefits and covered services and is not a contract. Please refer to yourCertificate Booklet Form # F-1681.801 (the contract) for a complete explanationof covered services, limitations and exclusions.For more information regarding our products and locating a provider, visit our Web Sitewww.bcbsga.com.

3350 Peachtree Road, NE Atlanta, Georgia 30326 1-800-441-2273Independent Licensee of the Blue Cross Blue Shield Association® Registered Mark of the Blue Cross Blue Shield AssociationBEN0106 - eff 10/15/09 (MHPA updates)