Your Plan: BCBSHP Core DirectAccess Plus gwnb Your Network: Blue Open Access POS 10PH B-OAP2F 6K/0 6.3K This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal contract of coverage. If there is a difference between this summary and the contract of coverage, the contract of coverage will prevail. In-network Provider Out-of-network Provider Overall Deductible Member: $6,000 Member: $12,000 Deductibles and out-of-pocket maximums are added separately for in-network and outof-network services. One family member may reach his or her Individual deductible and be eligible for coverage on health care expenses before other family members. Each family member’s deductible amount also goes toward the Family deductible and out-ofpocket maximum. Not everyone has to meet his or her deductible and out-of-pocket maximum for the family to meet theirs. When the Family deductible is met, all family members can access coverage for health care expenses. See notes below to understand how your deductible works. Your plan has a separate Prescription Drug Deductible. See Retail Prescription Drug Coverage section. For Family: $12,000 For Family: $24,000 Out-of-Pocket Limit Member: $6,350 Member: $12,700 When you meet your out-of-pocket limit, you will no longer have to pay cost-shares during the remainder of your benefit period. Your copays, coinsurance and deductibles count toward your out-of-pocket limit. If Pediatric Vision and/or Dental services are covered under this plan, these services count towards your out of pocket limit. Your plan has a separate prescription drug out-of-pocket limit (see Retail Prescription Drug Coverage). For Family: $12,700 For Family: $25,400 Covered Medical Benefits Cost if you use an Innetwork Provider Cost if you use an Outof-network Provider Doctor Home and Office Services Preventive care Covered in full (not subject to deductible) **Primary care visit to treat an injury or illness $35 copay 30% coinsurance after deductible **Specialist care visit $60 copay 30% coinsurance after deductible Prenatal and post-natal visit 0% coinsurance after deductible 30% coinsurance after deductible $35 copay 30% coinsurance after deductible **Other practitioner visits: **Retail health clinic **Chiropractor services $35 copay 30% coinsurance after deductible Limited to 20 visits across outpatient and other professional visits. (Combined for Chiropractic and Osteopathic services.) 0% coinsurance after deductible 30% coinsurance after deductible Chemo/radiation therapy 0% coinsurance after deductible 30% coinsurance after deductible Hemodialysis 0% coinsurance after 30% coinsurance after Other services in an office: Allergy testing Questions: 1-855-837-8541 or visit us at www.bcbsga.com GA-OAP-R2B1-L-B-O-1-1-2014 (Track 2L) 30% coinsurance after deductible (deductible waived through age 5) In-network preventive care is not subject to deductible, if your plan has a deductible. Page 1 of 7 Prescription drugs Covered Medical Benefits Diagnostic Services Lab: Office Freestanding lab Outpatient hospital X-ray: Office Freestanding radiology center Outpatient hospital deductible deductible 0% coinsurance after deductible 30% coinsurance after deductible Cost if you use an Innetwork Provider Cost if you use an Outof-network Provider 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 0% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible $250 copay + 0% coinsurance Same as in-network 0% coinsurance after deductible Same as in-network Same as in-network Covered when medically necessary 0% coinsurance after deductible Urgent care (office setting) $60 copay 30% coinsurance after deductible $35 copay 30% coinsurance after deductible Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Office Freestanding radiology center Outpatient hospital Emergency and Urgent Care Emergency room facility services No coverage for non-emergency use of emergency room Emergency room doctor and other services No coverage for non-emergency use of emergency room Ambulance (air and ground) Outpatient Mental/Behavioral Health and Substance Abuse (*services must be authorized by calling 1-800-292-2879) Doctor office visit Questions: 1-855-837-8541 or visit us at www.bcbsga.com GA-OAP-R2B1-L-B-O-1-1-2014 (Track 2L) Page 2 of 7 Facility visit: Facility fees Doctor and other services Covered Medical Benefits Outpatient Surgery Facility fee: Hospital Freestanding surgical center Doctor and other services Hospital Stay (all inpatient stays including maternity, mental / behavioral health, and substance abuse) Facility fee (for example, room & board) Doctor and other services 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible Cost if you use an In-network Provider Cost if you use an Outof-network Provider 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible 0% coinsurance after deductible 30% coinsurance after deductible $35 copay 30% coinsurance after deductible Recovery & Rehabilitation Home health care Limited to 120 visits; limit does not apply to Physical, Occupational or Speech Therapy when performed as part of Home Health. Rehabilitation services (for example, physical/speech/occupational therapy): Office Outpatient hospital 0% coinsurance after deductible Limited to 20 combined visits for Phys & Occupat Therapy. 20 separate visits for Speech Therapy. Massage Therapy covered only when rendered by a physical therapist for treatmt of a disease/injury. Visit limits combined across outpt & other prof visits. Cardiac rehabilitation 30% coinsurance after deductible $35 copay 30% coinsurance after deductible 0% coins after deductible 30% coins after deductible 0% coinsurance after deductible 30% coinsurance after deductible Office Outpatient hospital Skilled nursing care (in a facility) Skilled Nursing Facility and Rehab conducted in a Skilled Nursing Facility setting Questions: 1-855-837-8541 or visit us at www.bcbsga.com GA-OAP-R2B1-L-B-O-1-1-2014 (Track 2L) Page 3 of 7 is limited to 30 combined days. Durable medical equipment & prosthetics Covered Prescription Drug Benefits 0% coinsurance after deductible 30% coinsurance after deductible Cost if you use an In-network Provider Cost if you use an Outof-network Provider Retail Prescription Drug Coverage This plan uses a Select Drug List. Drugs not on the list are not covered. This plan includes Home Delivery (Mail Order). Home Delivery copays are 2.5 times retail copays for 90 day supply. Notes: If a member receives a brand name drug that falls on Tier 2 or Tier 3 that has a generic equivalent available, the member pays the Tier 1 copay, plus the difference in cost between the brand drug and generic drug. This applies even when physician indicates DAW (dispense as written) or obtains an authorization. Members must file a claim form for reimbursement when using an out-of-network pharmacy. Specialty drugs can only be obtained from a Specialty Pharmacy. Out-of-Pocket limit Your prescription plan has a separate pharmacy out-of-pocket limit: the family out-ofpocket limit is 2 times the per-member amount shown here. Both in-network and out-ofnetwork services count toward your drug out-of-pocket limit. Deductible Your prescription drug deductible applies to Tiers 2,3, and 4 only,and is combined innetwork and out-of-network if your plan includes out-of-network coverage. Drug OOP Max (Member) : $6,350 Drug OOP Max (Family) : $12,700 Drug Deductible (Member) : $400 Drug Deductible (Family) : $800 Drug tier 1 $15 copay (retail) 30% coinsurance *30 day at retail; 90 day at mail order $38 copay (mail order) No OON Mail Drug tier 2 $50 copay (retail) 30% coinsurance *30 day at retail; 90 day at mail order $125 copay (mail order) No OON Mail Drug tier 3 $90 copay (retail) 30% coinsurance *30 day at retail; 90 day at mail order $225 copay (mail order) No OON Mail Drug tier 4 30% coinsurance 30% coinsurance No OON Mail Drug tier 4 per-prescription maximum cost share (in-network only) Questions: 1-855-837-8541 or visit us at www.bcbsga.com GA-OAP-R2B1-L-B-O-1-1-2014 (Track 2L) $500 Page 4 of 7 Covered Vision Benefits Cost if you use an Innetwork Provider This is a brief outline of your in-network coverage. Not all cost shares for covered services are shown below. For a full list, including benefits, exclusions and limitations, and out-of-network coverage (If applicable), see the combined Evidence of Coverage/Disclosure Form/Certificate. If there is a difference between this summary and either Evidence of Coverage/Disclosure form/Certificate, the Evidence of Coverage/Disclosure form/Certificate will prevail. In-network Pediatric Vision benefit cost shares accumulate to the Medical plan out-of-pocket limit and are not subject to the Medical plan deductible, if your plan includes a deductible. Adult Vision services are covered. (See below and your Evidence of Coverage for details.) Children's Vision Essential Health Benefits Vision exam (once every calendar year) Covered in full Frames (once every calendar year) Covered in full Lenses (once every calendar year) Covered in full Elective contact lenses (once every calendar year) Covered in full Adult Vision Vision exam (once every calendar year) $20 copay Frames (once every other calendar year) $0 copay, $130 frame allowance Lenses (once every other calendar year) $20 copay Elective contact lenses (once every other calendar year) $0 copay, $80 allowance Questions: 1-855-837-8541 or visit us at www.bcbsga.com GA-OAP-R2B1-L-B-O-1-1-2014 (Track 2L) Page 5 of 7 Your plan also includes the following Healthy Support features Healthy Lifestyles Online Online well-being health improvement program focused on physical, social and emotional behaviors, including healthy eating, exercise and weight management Quarterly Health Webinars One hour health education seminars delivered via the web Gym membership reimbursement Members are rewarded for regular visits to their gym Up to $400 / year Healthy Lifestyles incentives Members track rewards online for participating in Healthy Lifestyles Up to $150 / year in gift cards Tobacco free certification with incentives By certifying online, members are rewarded for being tobacco free $50 / year gift card FitOrbit Access to online trainers and nutrition plans $99 / year per member cost Questions: 1-855-837-8541 or visit us at www.bcbsga.com GA-OAP-R2B1-L-B-O-1-1-2014 (Track 2L) Page 6 of 7 Notes: • All medical services subject to a coinsurance are also subject to the annual medical deductible. • If your plan includes a hospital stay copay and you are readmitted within 72 hours of a prior admission for the same diagnosis, your hospital stay copay for your readmission is waived. • If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your emergency room facility copay is waived. • If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in and out of network. • When using out-of-network providers, members are responsible for any difference between the Maximum Allowed Amount and the amount the provider actually charges, as well as any copayments, deductibles and/or applicable coinsurance. • Human Organ and Tissues Transplants require precertification and are covered as any other service in your summary of benefits. • If you elect a medical plan that does not include qualified Pediatric/Children’s Dental coverage you will be enrolled in a separate Children’s Dental plan, unless notification is received that you have enrolled in coverage elsewhere. • If your plan includes out of network benefit and you use a non-participating provider, you are responsible for any difference between the covered expense and the actual non-participating providers charge. • Physical Therapy: Athletic Trainers are covered by mandate for out-of-network only since athletic trainers are not contracted nor credentialed, therefore are not “in-network”. • For additional information on this plan, please visit sbc.bcbsga.com to obtain a Summary of Benefit Coverage. • Blue Cross and Blue Shield of Georgia 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. Questions: 1-855-837-8541 or visit us at www.bcbsga.com GA-OAP-R2B1-L-B-O-1-1-2014 (Track 2L) Page 7 of 7
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