Your Right Plan PPO Benefits At A Glance

Authorized Agent*

Blue Cross Blue Shield of GA Right Plan PPO No Deductible Plan*
Description of Benefits		In-Network Coverage	Out-of-Network Coverage
Lifetime Maximum Per Member		$5,000,000	$5,000,000
Annual Deductible Per Member (3 person max)		$0	$0
Annual Out-of-Pocket Maximum		$7,500	$7,500
Office Visits - (Preferred Physicians and Specialists-includes X-ray and lab work when performed in the physician's office)		$40	Plan pays 60%
Preventive Care for Babies and Children (through age 6)		$40	Plan pays 60%
Preventive Care for Adults ($250 benefit max. per year)		$40	Plan pays 60%
Professional Services Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab.		Plan pays 60%	Plan pays 60%
Inpatient Hospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants		Plan pays 60% + $500 copayment per admission	Plan pays 60% + $500 copayment per admission
Maternity (Available on Family Contracts Only) - Note: No maternity benefits are payable for the first 12 months of coverage.		NOT COVERED	NOT COVERED
Outpatient Medical Care		Plan pays 60% + $500 copayment per surgery facility	Plan pays 60% + $500 copayment per surgery facility
Physical/Occupational Therapy, Chiropractic (Limited to 30 visits per year combined)		Plan pays 60%	Plan pays 60%
Mental, Emotional or Functional Nervous Disorders - Hospital Inpatient Only - Outpatient not covered		$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		Plan pays 60%	Plan pays 60%
Emergency Room Care - For Medical Emergency or Serious Accidental Injury For Non-Medical Emergency or Non-serious Accidental Injury		$150 copay then 100% coverage Plan pays 60%	$150 copay then 100% coverage Plan pays 60%
Ambulatory Surgical Center		Plan pays 60% + $500 copayment per surgery	Plan pays 60% + $500 copayment per surgery
Ambulance Service		Plan pays 60%	Plan pays 60%
Home Health Care Maximum of 100 visits per year for preferred and non-preferred providers combined		Plan pays 60%	Plan pays 60%
Speech/Respiratory Therapy/Skilled Nursing Maximum of 30 visits per year per specialty		Plan pays 60%	Plan pays 60%
Hospice Maximum lifetime covered expense of $10,000		Plan pays 60%	Plan pays 60%
Home Health Care - Maximum of 100 visits per year		Plan pays 60%	Plan pays 60%
Durable Medical Equipment and Prosthetics		Plan pays 60%	Plan pays 60%
Private Duty Nursing $2,500 per year maximum		Plan pays 60%	Plan pays 60%
Prescription Drugs - $200 Deductible Per Year for non-generic Drugs - per prescription (up to a 30-day supply)		After a $200 Deductible Per Year for non-generic Drugs - per prescription (up to a 30-day supply) you pay:	After a $200 Deductible Per Year for non-generic Drugs - per prescription (up to a 30-day supply) you pay:
	Generic	$15 copayment (no deductible)	$15 copayment (no deductible)
	Brand Formulary	$30 copayment	$30 copayment
	Non-Brand Formulary	$45 copayment	$45 copayment
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 Bob or Holly 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 is an independent licensee of the Blue Cross Blue Shield Association