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High Deductible PPO In-Network Benefit Summary* (click here for out-of-network benefit summary)
Description of Benefits (Individual/family deductible then % Covered by insurance)		1,150 / 2,300 Ded 100% Plan	1,800 / 3,500 Ded 100% Plan	2,600 / 5,150 Ded 100% Plan	1,150 / 2,300 Ded 80% Plan	1,800 / 3,500 Ded 80% Plan	2,600 / 5,150 Ded 80% Plan
Lifetime Maximum Per Member		$5,000,000	$5,000,000	$5,000,000	$5,000,000	$5,000,000	$5,000,000
Annual Deductible: Individual Family		$1,000 $2,000	$1,800 $3,500	$2,600 $5,150	$1,000 $2,000	$1,800 $3,500	$2,600 $5,150
Annual Out-of-Pocket Maximum: Individual Family		$1,000 $2,000	$1,800 $3,500	$2,600 $5,150	$3,000 $6,000	$4,000 $8,000	$5,000 $10,000
Office Visits - (PPO Physicians and Specialists- includes X-ray and lab work when performed and billed by the physician's office)		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Preventive Care for Babies and Children (through age 5)		Plan pays 100% with deductible waived	Plan pays 100% with deductible waived	Plan pays 100% with deductible waived	Plan pays 80% with deductible waived	Plan pays 80% with deductible waived	Plan pays 80% with deductible waived
Preventive Care for Adults ($250 benefit max. per year)		Plan pays 100% with deductible waived	Plan pays 100% with deductible waived	Plan pays 100% with deductible waived	Plan pays 80% with deductible waived	Plan pays 80% with deductible waived	Plan pays 80% with deductible waived
Professional Services Including surgery, anesthesia in-hospital physician care, diagnostic X-ray and lab.		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Inpatient Hospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Maternity (Available on Family Contracts Only) Note: No maternity benefits are payable for the first 12 months of coverage.		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Outpatient Medical Care		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Physical/Occupational Therapy, Chiropractic (Limited to 30 visits per year combined)		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Mental, Emotional or Functional Nervous Disorders - Hospital Inpatient Only - Outpatient is not a covered benefit		$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum
Infusion Therapy/Chemotherapy		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Emergency Room Care		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Ambulatory Surgical Center		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Ambulance Service		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Home Health Care Maximum of 100 visits per year for preferred and non-preferred providers combined		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Speech/Respiratory Therapy/Skilled Nursing Maximum of 30 visits per year per specialty		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Hospice Maximum lifetime covered expense of $10,000		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Home Health Care - Maximum of 100 visits per year		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Durable Medical Equipment and Prosthetics		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Private Duty Nursing $2,500 per year maximum		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Prescription Drugs - Includes Generic, Brand Formulary and Non-Brand Formulary		100% after deductible	100% after deductible	100% after deductible	80% after deductible	80% after deductible	80% after deductible
Waiting period for all pre-existing conditions is at least one year from contract effective date. *Refer to your individual certificate of coverage for complete benefit details
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9 Dunwoody Pk. South Suite 136 Atlanta, GA 30338	Call Chris, Holly or Bob at (770) 396-9517 Outside of the Atlanta area, call toll-free: 1-877-711-8376. Email: holly@insurance-now.com
*Blue Cross and Blue Shield of Georgia, Inc., is an independent licensee 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.