Your In-Network Blue Value PPO Benefits At A Glance

Authorized Agent*

Blue Value PPO In-Network Benefit Summary* (click here for out-of-network benefit summary)
Description of Benefits		Blue Value 1,000	Blue Value 2,000	Blue Value 3,000	Blue Value 3,500	Blue Value 5,000	Blue Value 10,000
Lifetime Maximum Per Member		$5,000,000	$5,000,000	$5,000,000	$5,000,000	$5,000,000	$5,000,000
Annual Deductible Per Member (3 person maximum)		$1,000	$2,000	$3,000	$3,500	$5,000	$10,000
Annual Out-of-Pocket Maximum (3 person family maximum)		$2,000 plus deductible per member	$2,000 plus deductible per member	$2,000 plus deductible per member	$2,000 plus deductible per member	$2,000 plus deductible per member	$2,000 plus deductible per member
Office Visits - (PPO Physicians and Specialists-includes X-ray and lab work when performed and billed by the physician's office)		$40 copayment for 1st six (6) visits per member per year with deductible waived. After 6th visit, plan pays 70% after deductible is met.	$40 copayment for 1st six (6) visits per member per year with deductible waived. After 6th visit, plan pays 70% after deductible is met.	$40 copayment for 1st six (6) visits per member per year with deductible waived. After 6th visit, plan pays 70% after deductible is met.	$40 copayment for 1st six (6) visits per member per year with deductible waived. After 6th visit, plan pays 70% after deductible is met.	$40 copayment for 1st six (6) visits per member per year with deductible waived. After 6th visit, plan pays 70% after deductible is met.	$40 copayment for 1st six (6) visits per member per year with deductible waived. After 6th visit, plan pays 70% after deductible is met.
Preventive Care for Babies and Children (through age 5)		Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived
Preventive Care for Adults ($250 benefit max. per year in addition to state mandated coverages)		Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived
Professional Services Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab.		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Inpatient Hospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Maternity (Available on Family Contracts Only) - Note: No maternity benefits are payable for the first 12 months of coverage.		Plan pays 70% after deductible	Plan pays 70% after deductible	Family Contracts Only: $3000 copay, then 100% Coverage	NOT COVERED	NOT COVERED	NOT COVERED
Outpatient Medical Care		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Physical/Occupational Therapy, Chiropractic (Limited to 30 visits per year combined)		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% 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		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
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 at 70% after deductible plus $150 ER Copay	$150 copay then 100% coverage Plan pays at 70% after deductible plus $150 ER Copay	$150 copay then 100% coverage Plan pays at 70% after deductible plus $150 ER Copay	$150 copay then 100% coverage Plan pays at 70% after deductible plus $150 ER Copay	$150 copay then 100% coverage Plan pays at 70% after deductible plus $150 ER Copay	$150 copay then 100% coverage Plan pays at 70% after deductible plus $150 ER Copay
Ambulatory Surgical Center		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Ambulance Service		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Home Health Care Maximum of 100 visits per year for preferred and non-preferred providers combined		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Speech/Respiratory Therapy/Skilled Nursing Maximum of 30 visits per year per specialty		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Hospice Maximum lifetime covered expense of $10,000		Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived
Home Health Care - Maximum of 100 visits per year		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Durable Medical Equipment and Prosthetics		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Private Duty Nursing $2,500 per year maximum		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Prescription Drugs - Retail Drugs - per prescription (up to a 30-day supply)		After a $200 deductible per person, you pay:	After a $200 deductible per person, you pay:	After a $200 deductible per person, you pay:{Does not apply to generic drugs}	After a $350 deductible per person, you pay:	After a $500 deductible per person, you pay:	After a $1,000 deductible per person, you pay:
	Generic	$15 copayment	$15 copayment	$15 copayment	$15 copayment	$15 copayment	$15 copayment
	Brand Formulary	$30 copayment	$30 copayment	$30 copayment	$30 copayment	$30 copayment	$30 copayment
	Non-Brand Formulary	$45 copayment	$45 copayment	$45 copayment	$45 copayment	$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 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 is an independent licensee of the Blue Cross Blue Shield Association