2015 Small Group Guide
For groups with 2-50 employees
Effective January 1, 2015
37046GABENBGA Rev. 08/14
The Affordable Care Act
(ACA) is transforming the
health care marketplace
Access to the latest range of plans
Introduced in 2014, Blue Cross and Blue Shield of Georgia
(BCBSGa) plans are well-positioned for the changing market.
You’ll find they offer all the essential health benefits (EHB)
such as emergency care, hospital stays, maternity and
newborn care, prescription drugs and preventive care, as well
as other features needed to comply with the Affordable Care
Act (ACA). Yet they still deliver on our longstanding portfolio
strengths, including network value, plan variety, pharmacy
coverage and comprehensive care.
Built from the ground up — with the strengths
you’ve come to expect from the BCBSGa
product portfolio
We think you’ll find the BCBSGa plans are
well-positioned for the changing market. They provide all
the essential health benefits and other features required for
ACA compliance. At the same time, you’ll see that they were
carefully designed to be as cost-effective as possible, while
still maintaining our traditional portfolio strengths:
Network Value — BCBSGa works with a large network of
doctors and hospitals to ensure that employees and their
families get access to high-quality care at a lower cost.
}}
Plan Variety — We provide a wide choice of plans and
designs to suit evolving needs and provide extensive tools
and guidance to help employers find the best match.
}}
Pharmacy – We provide pharmacy coverage with a
variety of options and features to help employers — and
employees — control costs.
}}
Comprehensive Care — With free preventive care, free
access to the 24/7 NurseLine and integrated clinical and
wellness programs, we can provide a complete health
and wellness solution for employees.
}}
Stability — Our companies have been providing health
care benefits to millions of Americans, and we use that
experience to your advantage every day.
}}
2
The BCBSGa product portfolio
Every plan in our portfolio is ACA-compliant, covering
everything from emergencies to counseling services to
preventive care, and more, including:
}}Preventive, wellness and chronic disease
management services
}}Outpatient (ambulatory) care
}}Emergency services, including emergency room
or urgent care
}}Inpatient care (hospital stays)
}}Laboratory services
}}Prescription drugs
}}Mental health and substance abuse
}}Maternity (pregnancy) and newborn care
}}Pediatric dental and vision essential health benefits
}}Rehabilitative and habilitative services and devices
(habilitative services help a person learn, keep or
improve skills they may not be developing normally)
Bundle BCBSGa’s leading dental, vision, life and disability
products with our health plans for a more comprehensive,
easy-to-administer offering for your employees.
To find a network doctor, hospital or pharmacy, use our
online Provider Directory at bcbsga.com.
What’s New
BCBSGa is providing the portfolio of plans you have come
to know and trust, offered on the networks you have
relied on. The plan names may have changed, but the plans
have not. Plans are now categorized as Platinum, Gold,
Silver, and Bronze for our off-exchange products,
but we are still offering them on the same networks:
HMO BlueChoice Healthcare Plan, Blue Open Access POS
and Blue Choice PPO, and Pathway.
The chart starting on page 6 shows our plan names on the
associated networks, to help guide you to the plan that is
right for you and your employees. Also, our online plan
comparison tool at bcbsgaplancomparison.com will
compare plans side by side.
Balance Funding
Our new balance funding product may be a good option
for groups 10-99.
Changes to look for in 2015
Updated naming structure is clearer and
more complete
The plan names include the following elements: BCBSHP +
metal tier + network name + product type + deductible
/coinsurance/out-of-pocket maximum.
Example: BCBSHP Silver Blue Open Access POS
4000/20%/6600
Our plans meet ACA-metal level requirements: platinum,
gold, silver and bronze. The difference between these
levels is the actuarial value. In other words, a plan, on average, must cover a defined percentage of medical costs in
order to meet the metal level requirements.
Here’s what it means when you see the “Plus” in the
plan name
When the “Plus” is added to a plan name (as in “BCBSHP
Gold Pathway Enhanced POS 500/20%/5000 Plus”), it
means the plan contains the following:
}}Healthy Support Package B — A robust health and
wellness offering with online resources and webinars,
plus fitness reimbursements and health incentives of
up to $600/year.
Pediatric dental is embedded within all plans
The ACA is written so all children have access to affordable
dental care to keep their teeth and gums healthy. It’s part
of the essential health benefits (EHB) included in all
medical plans. Other required EHBs that are embedded in
member medical plans include emergency care, hospital
stays, maternity and newborn care, prescription drugs and
preventive care.
Composite Rating/Premium
Composite rating, as it’s been applied in the past, is no
longer allowed. However, “composite premiums” may be
used. They must be equal to the sum of the age-rated
premium for all covered employees and dependents of
the group, divided by the number of members covered:
}}A composite premium structure may be used for
small business plan years, starting on or after
January 1, 2015.
The composite premiums calculated at the time of
issue or renewal must be locked in for the entire plan
year, regardless of changes in the group’s composition
throughout the year.
}}
3
Products & features
On the pages that follow, you will find product grids that provide a top line description of the complete range of
BCBSGa plans. The explanations below correspond to column headers found on those grids. Deductibles, copays
and coinsurance amounts are also listed to simplify plan comparison.
Plan Name
Platinum plans — These provide the highest level of benefits, and employees often pay less when they get care. However, these plans
have the highest monthly premiums.
Gold plans — These provide richer benefits than the Silver and Bronze plans, and employees pay less when they get care. However, the
monthly premium is higher than with those plans.
Silver plans — These offer affordable monthly premiums, but compared to the Bronze plans, employees pay less when they get care.
Bronze plans — These feature broad benefits and the lowest monthly premiums, but employees pay more when they get care:
deductibles, copays and cost shares may be higher than the other plans.
Metal equivalent naming structure — Actuarial values can be used to compare different plan designs to determine how overall cost
sharing differs across plans with different cost-sharing provisions.
Product Type
Minimum AV
Maximum AV
Platinum
88%
92%
Gold
78%
82%
Silver
68%
72%
Bronze
58%
62%
Non-gatekeeper (PPO/POS) — Allows members to go directly to any in-network provider. There is no need to choose a primary care
physician (PCP) or get a referral to see other doctors.
Gatekeeper (HMO) — Requires members to choose a primary care physician (PCP); a referral may be required to see other doctors.
Health Savings Account (HSA) — A savings account for certain plans that members can fund with pre-tax dollars and used to pay for
qualified health care expenses, including prescriptions. This is often used with a Consumer Driven Health Plan.
Health Reimbursement Arrangements (HRA) — A health plan that comes with a special type of bank account. The employer puts
money into the account and the members use the money to pay for qualified (certain) health costs that are not covered by the health plan.
Pharmacy
The BCBSGa drug list is a list of FDA-approved generic and brand-name medications. The list is divided into four tiers. Tier 1 drugs
have the lowest out-of-pocket costs. Tier 2 drugs are slightly higher. Tier 3 and Tier 4 drugs have the highest out-of-pocket costs. In
evaluating a plan, it is important to look at the drug list to understand which drugs are covered.
All of our ACA-compliant products include our BCBSGa Select Drug List. Our Balance Funding products use the National Formulary List.
4
Pediatric Vision EHB
w
All of our small group medical plans include pediatric vision essential health benefits, which provide coverage for vision exams and glasses
or contacts. Members can see any provider in the Blue View Vision network, which includes retailers such as LensCrafters® and Target
Optical®, as well as 1-800 CONTACTS.
Covered children can choose from a selection of frames and contact lenses. Glasses with Transitions® lenses (to protect eyes from UV rays)
and polycarbonate lenses with scratch coating (to protect lenses from damage) are available at no extra charge.
BCBSGa Vision Pediatric
Routine eye exam (once every calendar year)
Lenses - single, bifocal, trifocal (once every calendar year)
Lens treatments
UV coating
Standard factory scratch coating
Standard polycarbonate
Standard Transitions®
Standard progressive lenses
Frames (once every calendar year)
Elective contact lenses (once every calendar year - in lieu of eyeglasses)
In-network
$0 copay
$0 copay
Covered in full
Covered in full
Covered in full
Covered in full
Covered in full
Covered in full
$0 copay, Formulary
$0 copay, Formulary
Non-elective contact lenses
Covered in full
If you have a PPO/POS medical plan, it will include out-of-network benefits for vision.
Pediatric Dental EHB
All of our small group health plans include pediatric dental EHBs, which provide important coverage for kids up to age 19, including preventive
care, fillings and more extensive services like medically necessary orthodontia. Members can see any provider in the Dental Prime network.
Diagnostic and preventive services (cleanings, exams and X-rays) – not subject to deductible
Basic services (fillings)
Endodontic, periodontal, oral surgery and major services
Medically necessary orthodontia (12-month waiting period)]
In and out-of-network
90%
60%
60%
60%
Because these benefits are part of a medical plan, they share a combined deductible and out-of-pocket maximum. Diagnostic and preventive
services like cleanings, exams and X-rays are not subject to the deductible, so members can take advantage of them right away. These
benefits have no annual maximum.
* If the member’s medical plan includes out-of-network benefits, the dental benefits will also be available through out-of-network providers. If the member’s medical plan only includes in-network benefits, the dental benefits
will only be available through in-network providers.
w
Healthy Support
Healthy Support Package B —
}} Includes Healthy Lifestyles online and webinars
}} Includes Fitness Reimbursement (up to $400/yr in cash)
}} Includes Healthy Incentives (up to $200/yr in gift cards)
}} FitOrbit (online trainers and nutrition plans) with member cost share ($99/yr)
Includes Vision (annual exam + $100 for lenses/frames)
5
Contract Offered
code
on/off
exchange
Product
name
1KHK
Off
1KGC
Network Metal
type
OOP
Deductible Deductible Other
family
coins
PCP
Tier 1
SPC
Home
health
BCBSHP Silver Blue Open
Blue Open
Access POS 4000/30%/6350 Access POS
POS
Silver
$6,350 $12,700
$4,000
$8,000
30%
$35
$50
$35
Off
BCBSHP Silver Blue Open
Access POS 3000/20%/6600
Blue Open
Access POS
POS
Silver
$6,600 $13,200
$3,000
$6,000
20%
$35
$60
$35
1KBQ
Off
BCBSHP Platinum Blue Open
Access POS 10%/2500
Blue Open
Access POS
POS
Platinum $2,500 $5,000
N/A
N/A
10%
$10
$20
$10
1KBT
Off
BCBSHP Platinum BlueChoice
HMO 10%/2500
BlueChoice
HMO
HMO
Platinum $2,500 $5,000
N/A
N/A
10%
$10
$20
$10
1KE2
Off
BCBSHP Gold Blue Open
Access POS 2000/0%/4000
Blue Open
Access POS
POS
Gold
$4,000 $8,000
$2,000
$4,000
0%
$30
$50
$30
1KCL
Off
BCBSHP Gold Blue Open
Access POS 1500/0%/2500
Blue Open
Access POS
POS
Gold
$2,500 $5,000
$1,500
$3,000
0%
$30
$60
$30
1KE6
Off
BCBSHP Gold Blue Open
Access POS 1000/0%/4500
Blue Open
Access POS
POS
Gold
$4,500 $9,000
$1,000
$3,000
0%
$30
$60
$30
1KD9
Off
BCBSHP Gold Blue Open
Access POS 1500/15%/4000
Blue Open
Access POS
POS
Gold
$4,000 $8,000
$1,500
$3,000
15%
$30
$50
$25
1KCG
Off
BCBSHP Gold Blue Open
Access POS 1000/25%/5000
Blue Open
Access POS
POS
Gold
$5,000 $10,000
$1,000
$3,000
25%
$10
$50
$10
1KCD
Off
BCBSHP Bronze
Blue Open Access POS
5900/0%/6600 Plus
Blue Open
Access POS
POS
Bronze
$6,600 $13,200
$5,900
$11,800
0%
$35
$35
0%
1KDM
Off
BCBSHP Bronze
Pathway Enhanced POS
5900/0%/6600 Plus
Pathway
Enhanced
POS
Bronze
$6,600 $13,200
$5,900
$11,800
0%
$35
$35
0%
1KC2
Off
BCBSHP Gold
Blue Open Access POS
1000/20%/3000 Plus
Blue Open
Access POS
POS
Gold
$3,000 $6,000
$1,000
$3,000
20%
$20
$20
20%
1KC7
Off
BCBSHP Gold Pathway
Enhanced POS
1000/20%/3000 Plus
Pathway
Enhanced
POS
Gold
$3,000 $6,000
$1,000
$3,000
20%
$20
$20
20%
1KC3
Off
BCBSHP Silver
Blue Open Access POS
3500/0%/4500 Plus
Blue Open
Access POS
POS
Silver
$4,500 $9,000
$3,500
$7,000
0%
$30
$30
0%
1KBY
Off
BCBSHP Silver
Pathway Enhanced POS
3500/0%/4500 Plus
Pathway
Enhanced
POS
Silver
$4,500 $9,000
$3,500
$7,000
0%
$30
$30
0%
1KCA
Off
BCBSHP Silver
Pathway Enhanced POS
1500/35%/5500 Plus
Pathway
Enhanced
POS
Silver
$5,500 $11,000
$1,500
$3,000
35%
$35
$35
35%
1KC8
Off
BCBSHP Silver
Blue Open Access POS
1500/35%/5500 Plus
Blue Open
Access POS
POS
Silver
$5,500 $11,000
$1,500
$3,000
35%
$35
$35
35%
1KCC
Off
BCBSHP Silver
Pathway Enhanced POS
3000/20%/4500 Plus
Pathway
Enhanced
POS
Silver
$4,500 $9,000
$3,000
$6,000
20%
$30
$30
20%
1KBS
Off
BCBSHP Silver
Blue Open Access POS
3000/20%/4500 Plus
Blue Open
Access POS
POS
Silver
$4,500 $9,000
$3,000
$6,000
20%
$30
$30
20%
1KBZ
Off
BCBSHP Silver
Pathway Enhanced POS
2000/30%/5500 Plus
Pathway
Enhanced
POS
Silver
$5,500 $11,000
$2,000
$4,000
30%
$35
$35
30%
6
Network
name
OOP
family
Urgent care Urgent care ER copay
copay
percent
ER coins
Outpatient
copay
Output
percent
Inpatient
max days
Inpatient Inpatient RX benefit
copay
percent
Formulary
$50
N/A
$200
30%
N/A
30%
N/A
N/A
30%
$15/$35/$70/25%/$250
Select formulary
$60
N/A
$250
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$500
Select formulary
$20
N/A
$150
N/A
$150
NA
3
$250
N/A
$10/$30/$60/25%
Select formulary
$20
N/A
$150
N/A
$150
NA
3
$250
N/A
$10/$30/$60/25%
Select formulary
$50
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$60
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$60
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$50
N/A
$200
15%
N/A
15%
N/A
N/A
15%
$15/$35/$70/25%
Select formulary
$50
N/A
$200
25%
N/A
25%
N/A
N/A
25%
$15/$35/$70/25%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/30%/$500
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/30%/$500
Select formulary
N/A
20%
N/A
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/30%
Select formulary
N/A
20%
N/A
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/30%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/30%/$500
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/30%/$500
Select formulary
N/A
35%
N/A
35%
N/A
35%
N/A
N/A
35%
$15/$35/$70/30%/$500
Select formulary
N/A
35%
N/A
35%
N/A
35%
N/A
N/A
35%
$15/$35/$70/30%/$500
Select formulary
N/A
20%
N/A
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/30%/$250
Select formulary
N/A
20%
N/A
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/30%/$250
Select formulary
N/A
30%
N/A
30%
N/A
30%
N/A
N/A
30%
$15/$35/$70/30%/$250
Select formulary
7
8
Contract Offered
code
on/off
exchange
Product
name
Network
name
Network Metal
type
OOP
1KC1
Off
BCBSHP Silver
Blue Open Access POS
2000/30%/5500 Plus
Blue Open
Access POS
POS
Silver
1KCU
Off
BCBSHP Bronze
Blue Open Access POS
6000/30%/6600 Plus
Blue Open
Access POS
POS
1KER
Off
BCBSHP Bronze
Pathway Enhanced POS
6000/30%/6600 Plus
Pathway
Enhanced
1KDF
Off
BCBSHP Silver
Pathway Enhanced POS
2500/20%/6350 Plus
1KDD
Off
1KCR
OOP
family
Deductible Deductible Other
family
coins
PCP
Tier 1
SPC
Home
health
$5,500 $11,000
$2,000
$4,000
30%
$35
$35
30%
Bronze
$6,600 $13,200
$6,000
$12,000
30%
$35
$35
30%
POS
Bronze
$6,600 $13,200
$6,000
$12,000
30%
$35
$35
30%
Pathway
Enhanced
POS
Silver
$6,350 $12,700
$2,500
$5,000
20%
$30
$60
$30
BCBSHP Silver
Blue Open Access POS
2500/20%/6350 Plus
Blue Open
Access POS
POS
Silver
$6,350 $12,700
$2,500
$5,000
20%
$30
$60
$30
Off
BCBSHP Silver
Pathway Enhanced POS
6350/0%/6350 Plus
Pathway
Enhanced
POS
Silver
$6,350 $12,700
$6,350
$12,700
0%
$30
$60
$30
1KD0
Off
BCBSHP Silver
Blue Open Access POS
6350/0%/6350 Plus
Blue Open
Access POS
POS
Silver
$6,350 $12,700
$6,350
$12,700
0%
$30
$60
$30
1KDP
Off
BCBSHP Gold Blue Open
Access POS 30%/5500
Blue Open
Access POS
POS
Gold
$5,500 $11,000
N/A
N/A
30%
$35
$60
$35
1KDR
Off
BCBSHP Gold BlueChoice
HMO 30%/5500
BlueChoice
HMO
HMO
Gold
$5,500 $11,000
N/A
N/A
30%
$35
$60
$35
1KD2
Off
BCBSHP Platinum Blue Open
Access POS 0%/2000
Blue Open
Access POS
POS
Platinum $2,000 $4,000
N/A
N/A
0%
$20
$40
$20
1KCS
Off
BCBSHP Platinum BlueChoice
HMO 0%/2000
BlueChoice
HMO
HMO
Platinum $2,000 $4,000
N/A
N/A
0%
$20
$40
$20
1KG0
Off
BCBSHP Gold Blue Open
Access POS 1000/20%/4500
Blue Open
Access POS
POS
Gold
$4,500 $9,000
$1,000
$3,000
20%
$15
$35
$15
1KH6
Off
BCBSHP Gold Blue Open
Access POS 1500/20%/6000
Blue Open
Access POS
POS
Gold
$6,000 $12,000
$1,500
$3,000
20%
$10
$35
$10
1KGU
Off
BCBSGA Gold BlueChoice PPO
1500/20%/6000
BlueChoice
PPO
PPO
Gold
$6,000 $12,000
$1,500
$3,000
20%
$10
$35
$10
1KFY
Off
BCBSHP Gold Blue Open
Access POS 1500/30%/4500
Blue Open
Access POS
POS
Gold
$4,500 $9,000
$1,500
$3,000
30%
$20
$40
$20
1KGF
Off
BCBSHP Gold Blue Open
Access POS 2500/0%/3000
Blue Open
Access POS
POS
Gold
$3,000 $6,000
$2,500
$5,000
0%
$30
$60
$30
1KGK
Off
BCBSHP Gold Blue Open
Access POS 4500/0%/4500
Blue Open
Access POS
POS
Gold
$4,500 $9,000
$4,500
$9,000
0%
$30
$60
$30
1KGP
Off
BCBSGA Gold BlueChoice PPO
3500/0%/4250
BlueChoice
PPO
PPO
Gold
$4,250 $8,500
$3,500
$7,000
0%
$20
$40
$20
1KH5
Off
BCBSHP Gold Blue Open
Access POS 3500/0%/4250
Blue Open
Access POS
POS
Gold
$4,250 $8,500
$3,500
$7,000
0%
$20
$40
$20
1KGT
Off
BCBSGA Gold BlueChoice PPO
3000/0%/4000
BlueChoice
PPO
PPO
Gold
$4,000 $8,000
$3,000
$6,000
0%
$15
$35
$15
Urgent care Urgent care ER copay
copay
percent
ER coins
Outpatient
copay
Output
percent
Inpatient
max days
Inpatient Inpatient RX benefit
copay
percent
Formulary
N/A
30%
N/A
30%
N/A
30%
N/A
N/A
30%
$15/$35/$70/30%/$250
Select formulary
N/A
30%
$250
30%
$250
30%
N/A
$500
30%
$15/$35/$70/30%/$250
Select formulary
N/A
30%
$250
30%
$250
30%
N/A
$500
30%
$15/$35/$70/30%/$250
Select formulary
$60
N/A
$250
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/30%/$500
Select formulary
$60
N/A
$250
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/30%/$500
Select formulary
$60
N/A
$250
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/30%
Select formulary
$60
N/A
$250
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/30%
Select formulary
$60
N/A
$200
N/A
$250
N/A
3
$750
N/A
$15/$35/$70/25%
Select formulary
$60
N/A
$200
N/A
$250
N/A
3
$750
N/A
$15/$35/$70/25%
Select formulary
$40
N/A
$150
NA
$200
N/A
3
$500
N/A
$10/$30/$60/25%
Select formulary
$40
N/A
$150
N/A
$200
N/A
3
$500
N/A
$10/$30/$60/25%
Select formulary
$35
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$35
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%
Select formulary
$35
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%
Select formulary
$40
N/A
$200
30%
N/A
30%
N/A
N/A
30%
$15/$35/$70/25%
Select formulary
$60
N/A
$150
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$60
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$40
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$40
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$35
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%/$250
Select formulary
9
Contract Offered
code
on/off
exchange
Product
name
Network
name
Network Metal
type
OOP
1KGV
Off
BCBSHP Gold Blue Open
Access POS 3000/0%/4000
Blue Open
Access POS
POS
Gold
1KGZ
Off
BCBSGA Gold BlueChoice PPO
500/20%/3500
BlueChoice
PPO
PPO
1KH1
Off
BCBSHP Gold Blue Open
Access POS 500/20%/3500
Blue Open
Access POS
1KH4
Off
BCBSGA Gold BlueChoice PPO
1000/20%/4000
1KHT
Deductible Deductible Other
family
coins
PCP
Tier 1
SPC
Home
health
$4,000 $8,000
$3,000
$6,000
0%
$15
$35
$15
Gold
$3,500 $7,000
$500
$1,500
20%
$25
$50
$25
POS
Gold
$3,500 $7,000
$500
$1,500
20%
$25
$50
$25
BlueChoice
PPO
PPO
Gold
$4,000 $8,000
$1,000
$3,000
20%
$15
$50
$15
Off
BCBSHP Gold Blue Open
Blue Open
Access POS 1000/20%/4000 Access POS
POS
Gold
$4,000 $8,000
$1,000
$3,000
20%
$15
$50
$15
1KHM
Off
BCBSHP Gold Blue Open
Access POS 2500/20%/4250
Blue Open
Access POS
POS
Gold
$4,250 $8,500
$2,500
$5,000
20%
$20
$40
$20
1KH9
Off
BCBSHP Gold Blue Open
Blue Open
Access POS 1000/20%/3750 Access POS
POS
Gold
$3,750 $7,500
$1,000
$3,000
20%
$30
$60
$30
1KHX
Off
BCBSHP Gold Blue Open
Blue Open
Access POS 2000/20%/4000 Access POS
POS
Gold
$4,000 $8,000
$2,000
$4,000
20%
$25
$50
$25
1KHD
Off
BCBSHP Gold Blue Open
Blue Open
Access POS 1000/20%/3000 Access POS
POS
Gold
$3,000 $6,000
$1,000
$3,000
20%
$25
$50
$25
1KHJ
Off
BCBSHP Silver Blue Open
Access POS 1750/40%/6350
Blue Open
Access POS
POS
Silver
$6,350 $12,700
$1,750
$3,500
40%
$50
$75
$50
1KHZ
Off
BCBSGA Silver BlueChoice
PPO 4000/20%/6350
BlueChoice
PPO
PPO
Silver
$6,350 $12,700
$4,000
$8,000
20%
$50
$75
$50
1KJ5
Off
BCBSHP Silver Blue Open
Blue Open
Access POS 4000/20%/6350 Access POS
POS
Silver
$6,350 $12,700
$4,000
$8,000
20%
$50
$75
$50
1KEF
Off
BCBSGA Silver BlueChoice
PPO 5000/20%/6350
BlueChoice
PPO
PPO
Silver
$6,350 $12,700
$5,000
$10,000
20%
$40
$60
$40
1KDU
Off
BCBSHP Silver Blue Open
Blue Open
Access POS 5000/20%/6350 Access POS
POS
Silver
$6,350 $12,700
$5,000
$10,000
20%
$40
$60
$40
1KF5
Off
BCBSHP Silver Blue Open
Blue Open
Access POS 5500/30%/6350 Access POS
POS
Silver
$6,350 $12,700
$5,500
$11,000
30%
$35
$60
$35
1KFB
Off
BCBSHP Bronze
Blue Open Access POS
3500/30%/6350 w/ HSA
Blue Open
Access POS
POS
Bronze
$6,350 $12,700
$3,500
$7,000
30%
30%
30%
30%
1KFF
Off
BCBSHP Bronze
Blue Open Access POS
5500/0%/5500 w/ HSA
Blue Open
Access POS
POS
Bronze
$5,500 $11,000
$5,500
$11,000
0%
0%
0%
0%
1KF9
Off
BCBSHP Bronze
Blue Open Access POS
6300/0%/6300 w/ HSA
Blue Open
Access POS
POS
Bronze
$6,300 $12,600
$6,300
$12,600
0%
0%
0%
0%
1KD7
Off
BCBSHP Bronze
Blue Open Access POS
5000/20%/6350 w/HSA
Blue Open
Access POS
POS
Bronze
$6,350 $12,700
$5,000
$10,000
20%
$30
$60
20%
1KCV
Off
BCBSHP Bronze
Blue Open Access POS
4500/0%/6350 w/ HSA
Blue Open
Access POS
POS
Bronze
$6,350 $12,700
$4,500
$9,000
0%
$30
$60
0%
10
OOP
family
Urgent care Urgent care ER copay
copay
percent
ER coins
Outpatient
copay
Output
percent
Inpatient
max days
Inpatient Inpatient RX benefit
copay
percent
Formulary
$35
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%/$250
Select formulary
$50
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$50
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$50
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$50
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$40
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%
Select formulary
$60
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%
Select formulary
$50
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%
Select formulary
$50
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$10/$30/$60/25%
Select formulary
$75
N/A
$250
40%
N/A
40%
N/A
N/A
40%
$15/$35/$70/25%
Select formulary
$75
N/A
$250
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$75
N/A
$250
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$60
N/A
$250
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$500
Select formulary
$60
N/A
$250
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$500
Select formulary
$60
N/A
$250
30%
N/A
30%
N/A
N/A
30%
$15/$35/$70/25%/$750
Select formulary
N/A
30%
N/A
30%
N/A
30%
N/A
N/A
30%
Ded/30%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
$60
N/A
N/A
20%
N/A
20%
N/A
N/A
20%
Ded/$15/$35/$70/25%
Select formulary
$60
N/A
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/$15/$35/$70/25%
Select formulary
11
12
Contract Offered
Product
code
on/off
name
exchange
Network
name
Network Metal
type
OOP
1KEN
Off
BCBSHP Silver
Blue Open Access POS
3000/0%/3500 w/ HSA
Blue Open
Access POS
POS
Silver
1KEC
Off
BCBSHP Silver
Blue Open Access POS
2800/20%/3800 w/ HSA
Blue Open
Access POS
POS
1KEM
Off
BCBSHP Gold
Blue Open Access POS
3500/0%/3500 w/ HSA
Blue Open
Access POS
1KFH
Off
BCBSHP Gold
Blue Open Access POS
3500/0%/3500 w/ HRA
1KFN
Off
1KFS
OOP
family
Deductible Deductible Other
family
coins
PCP
Tier 1
SPC
Home
health
$3,500 $7,000
$3,000
$6,000
0%
$20
$40
0%
Silver
$3,800 $7,600
$2,800
$5,600
20%
$20
$35
20%
POS
Gold
$3,500 $7,000
$3,500
$7,000
0%
0%
0%
0%
Blue Open
Access POS
POS
Gold
$3,500 $7,000
$3,500
$7,000
0%
0%
0%
0%
BCBSHP Silver
Blue Open Access POS
3000/0%/3000 w/ HSA
Blue Open
Access POS
POS
Silver
$3,000 $6,000
$3,000
$6,000
0%
0%
0%
0%
Off
BCBSHP Silver
Blue Open Access POS
3500/0%/3500 w/ HSA
Blue Open
Access POS
POS
Silver
$3,500 $7,000
$3,500
$7,000
0%
0%
0%
0%
1KE4
Off
BCBSHP Silver
Blue Open Access POS
6350/0%/6350 w/ HSA
Blue Open
Access POS
POS
Silver
$6,350 $12,700
$6,350
$12,700
0%
0%
0%
0%
1KCN
Off
BCBSHP Silver
Blue Open Access POS
6000/0%/6000 w/ HRA
Blue Open
Access POS
POS
Silver
$6,000 $12,000
$6,000
$12,000
0%
0%
0%
0%
1KEK
Both
BCBSHP Gold Pathway
X Enhanced POS
500/20%/5000 Plus
Pathway X
Enhanced
POS
Gold
$5,000 $10,000
$500
$1,500
20%
$20
$20
20%
1KEJ
Both
BCBSHP Silver Pathway
X Enhanced POS
1500/30%/5500 Plus
Pathway X
Enhanced
POS
Silver
$5,500 $11,000
$1,500
$3,000
30%
$35
$35
30%
1KDG
Both
BCBSHP Bronze Pathway
X Enhanced POS
5000/30%/6600 Plus
Pathway X
Enhanced
POS
Bronze
$6,600 $13,200
$5,000
$10,000
30%
$30
$30
30%
1KD5
Off
BCBSHP Bronze
Pathway Enhanced POS
5000/20%/6350 w/ HSA
Pathway
Enhanced
POS
Bronze
$6,350 $12,700
$5,000
$10,000
20%
$30
$60
20%
1KEV
Off
BCBSHP Bronze
Pathway Enhanced POS
4500/0%/6350 w/HSA
Pathway
Enhanced
POS
Bronze
$6,350 $12,700
$4,500
$9,000
0%
$30
$60
0%
1KEQ
Off
BCBSHP Silver
Pathway Enhanced POS
3000/0%/3500 w/ HSA
Pathway
Enhanced
POS
Silver
$3,500 $7,000
$3,000
$6,000
0%
$20
$40
0%
1KEX
Off
BCBSHP Silver
Pathway Enhanced POS
2800/20%/3800 w /HSA
Pathway
Enhanced
POS
Silver
$3,800 $7,600
$2,800
$5,600
20%
$20
$35
20%
1KCX
Off
BCBSHP Bronze
Pathway Enhanced POS
5500/0%/5500 w/ HSA
Pathway
Enhanced
POS
Bronze
$5,500 $11,000
$5,500
$11,000
0%
0%
0%
0%
1KCQ
Off
BCBSHP Bronze
Pathway Enhanced POS
6300/0%/6300 w/ HSA
Pathway
Enhanced
POS
Bronze
$6,300 $12,600
$6,300
$12,600
0%
0%
0%
0%
1KFK
Off
BCBSHP Gold Pathway
Enhanced POS
3500/0%/3500 w /HSA
Pathway
Enhanced
POS
Gold
$3,500 $7,000
$3,500
$7,000
0%
0%
0%
0%
1KET
Off
BCBSHP Gold Pathway
Enhanced POS
3500/0%/3500 w/ HRA
Pathway
Enhanced
POS
Gold
$3,500 $7,000
$3,500
$7,000
0%
0%
0%
0%
1KFQ
Off
BCBSHP Silver
Pathway Enhanced POS
3000/0%/3000 w / HSA
Pathway
Enhanced
POS
Silver
$3,000 $6,000
$3,000
$6,000
0%
0%
0%
0%
Urgent care Urgent care ER copay
copay
percent
ER coins
Outpatient
copay
Output
percent
Inpatient
max days
Inpatient Inpatient RX benefit
copay
percent
Formulary
$40
N/A
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/$15/$35/$70/30%
Select formulary
$35
N/A
N/A
20%
N/A
20%
N/A
N/A
20%
Ded/$15/$35/$70/25%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
20%
N/A
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/30%
Select formulary
N/A
30%
N/A
30%
N/A
30%
N/A
N/A
30%
$15/$35/$70/30%/$500
Select formulary
N/A
30%
$250
30%
$250
30%
N/A
$500
30%
$15/$35/$70/30%/$500
Select formulary
$60
N/A
N/A
20%
N/A
20%
N/A
N/A
20%
Ded/$15/$35/$70/25%
Select formulary
$60
N/A
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/$15/$35/$70/25%
Select formulary
$40
N/A
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/$15/$35/$70/30%
Select formulary
$35
N/A
N/A
20%
N/A
20%
N/A
N/A
20%
Ded/$15/$35/$70/25%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
13
Contract Offered
code
on/off
exchange
Product
name
Network
name
Network Metal
type
OOP
1KEP
Off
BCBSHP Silver
Pathway Enhanced POS
3500/0%/3500 w/ HSA
Pathway
Enhanced
POS
Silver
1KEG
Off
BCBSHP Silver
Pathway Enhanced POS
6350/0%/6350 w/ HSA
Pathway
Enhanced
POS
1KDJ
Off
BCBSHP Silver
Pathway Enhanced POS
6000/0%/6000 w/ HRA
Pathway
Enhanced
1KE0
Off
BCBSHP Gold Pathway
Enhanced POS
2000/0%/4000
1KDY
Off
1KDW
Deductible Deductible Other
family
coins
PCP
Tier 1
SPC
Home
health
$3,500 $7,000
$3,500
$7,000
0%
0%
0%
0%
Silver
$6,350 $12,700
$6,350
$12,700
0%
0%
0%
0%
POS
Silver
$6,000 $12,000
$6,000
$12,000
0%
0%
0%
0%
Pathway
Enhanced
POS
Gold
$4,000 $8,000
$2,000
$4,000
0%
$30
$50
$30
BCBSHP Gold Pathway
Enhanced POS
1500/0%/2500
Pathway
Enhanced
POS
Gold
$2,500 $5,000
$1,500
$3,000
0%
$30
$60
$30
Off
BCBSHP Gold Pathway
Enhanced POS
1000/0%/4500
Pathway
Enhanced
POS
Gold
$4,500 $9,000
$1,000
$3,000
0%
$30
$60
$30
1KDC
Off
BCBSHP Gold Pathway
Enhanced POS
1500/15%/4000
Pathway
Enhanced
POS
Gold
$4,000 $8,000
$1,500
$3,000
15%
$30
$50
$25
1KCJ
Off
BCBSHP Gold Pathway
Enhanced POS
1000/25%/5000
Pathway
Enhanced
POS
Gold
$5,000 $10,000
$1,000
$3,000
25%
$10
$50
$10
1KG2
Off
BCBSHP Gold Pathway
Enhanced POS
1000/20%/4500
Pathway
Enhanced
POS
Gold
$4,500 $9,000
$1,000
$3,000
20%
$15
$35
$15
1KG1
Off
BCBSHP Gold Pathway
Enhanced POS
1500/20%/6000
Pathway
Enhanced
POS
Gold
$6,000 $12,000
$1,500
$3,000
20%
$10
$35
$10
1KG4
Off
BCBSHP Gold Pathway
Enhanced POS
1500/30%/4500
Pathway
Enhanced
POS
Gold
$4,500 $9,000
$1,500
$3,000
30%
$20
$40
$20
1KGH
Off
BCBSHP Gold Pathway
Enhanced POS
2500/0%/3000
Pathway
Enhanced
POS
Gold
$3,000 $6,000
$2,500
$5,000
0%
$30
$60
$30
1KGM
Off
BCBSHP Gold Pathway
Enhanced POS
4500/0%/4500
Pathway
Enhanced
POS
Gold
$4,500 $9,000
$4,500
$9,000
0%
$30
$60
$30
1KGR
Off
BCBSHP Gold Pathway
Enhanced POS
3500/0%/4250
Pathway
Enhanced
POS
Gold
$4,250 $8,500
$3,500
$7,000
0%
$20
$40
$20
1KGX
Off
BCBSHP Gold Pathway
Enhanced POS
3000/0%/4000
Pathway
Enhanced
POS
Gold
$4,000 $8,000
$3,000
$6,000
0%
$15
$35
$15
1KH3
Off
BCBSHP Gold Pathway
Enhanced POS
500/20%/3500
Pathway
Enhanced
POS
Gold
$3,500 $7,000
$500
$1,500
20%
$25
$50
$25
1KHF
Off
BCBSHP Gold Pathway
Enhanced POS
1000/20%/4000
Pathway
Enhanced
POS
Gold
$4,000 $8,000
$1,000
$3,000
20%
$15
$50
$15
1KHY
Off
BCBSHP Gold Pathway
Enhanced POS
2500/20%/4250
Pathway
Enhanced
POS
Gold
$4,250 $8,500
$2,500
$5,000
20%
$20
$40
$20
1KHP
Off
BCBSHP Gold Pathway
Enhanced POS
1000/20%/3750
Pathway
Enhanced
POS
Gold
$3,750 $7,500
$1,000
$3,000
20%
$30
$60
$30
1KHR
Off
BCBSHP Gold Pathway
Enhanced POS
2000/20%/4000
Pathway
Enhanced
POS
Gold
$4,000 $8,000
$2,000
$4,000
20%
$25
$50
$25
14
OOP
family
Urgent care Urgent care ER copay
copay
percent
ER coins
Outpatient
copay
Output
percent
Inpatient
max days
Inpatient Inpatient RX benefit
copay
percent
Formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
N/A
0%
N/A
0%
N/A
0%
N/A
N/A
0%
Ded/0%
Select formulary
$50
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$60
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$60
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$50
N/A
$200
15%
N/A
15%
N/A
N/A
15%
$15/$35/$70/25%
Select formulary
$50
N/A
$200
25%
N/A
25%
N/A
N/A
25%
$15/$35/$70/25%
Select formulary
$35
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$35
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%
Select formulary
$40
N/A
$200
30%
N/A
30%
N/A
N/A
30%
$15/$35/$70/25%
Select formulary
$60
N/A
$150
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$60
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$40
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%
Select formulary
$35
N/A
$200
0%
N/A
0%
N/A
N/A
0%
$15/$35/$70/25%/$250
Select formulary
$50
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$50
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$40
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%
Select formulary
$60
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%
Select formulary
$50
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%
Select formulary
15
16
Contract Offered
Product
code
on/off
name
exchange
Network
name
Network Metal
type
OOP
1KHV
Off
BCBSHP Gold
Pathway Enhanced POS
1000/20%/3000
Pathway
Enhanced
POS
Gold
1KGB
Off
BCBSHP Silver
Pathway Enhanced POS
3000/20%/6600
Pathway
Enhanced
POS
1KJ1
Off
BCBSHP Silver
Pathway Enhanced POS
1750/40%/6350
Pathway
Enhanced
1KJ7
Off
BCBSHP Silver
Pathway Enhanced POS
4000/20%/6350
1KHB
Off
1KF3
OOP
family
Deductible Deductible Other
family
coins
PCP Tier 1
SPC
Home
health
$3,000 $6,000
$1,000
$3,000
20%
$25
$50
$25
Silver
$6,600 $13,200
$3,000
$6,000
20%
$35
$60
$35
POS
Silver
$6,350 $12,700
$1,750
$3,500
40%
$50
$75
$50
Pathway
Enhanced
POS
Silver
$6,350 $12,700
$4,000
$8,000
20%
$50
$75
$50
BCBSHP Silver
Pathway Enhanced
4000/30%/6350
Pathway
Enhanced
POS
Silver
$6,350 $12,700
$4,000
$8,000
30%
$35
$50
$35
Off
BCBSHP Silver
Pathway Enhanced POS
5000/20%/6350
Pathway
Enhanced
POS
Silver
$6,350 $12,700
$5,000
$10,000
20%
$40
$60
$40
1KF7
Off
BCBSHP Silver
Pathway Enhanced POS
5500/30%/6350
Pathway
Enhanced
POS
Silver
$6,350 $12,700
$5,500
$11,000
30%
$35
$60
$35
1KFD
Off
BCBSHP Bronze
Pathway Enhanced POS
3500/30%/6350 w/ HSA
Pathway
Enhanced
POS
Bronze
$6,350 $12,700
$3,500
$7,000
30%
30%
30%
30%
Urgent care Urgent care ER copay
copay
percent
ER coins
Outpatient
copay
Output
percent
Inpatient
max days
Inpatient Inpatient RX benefit
copay
percent
Formulary
$50
N/A
$200
20%
N/A
20%
N/A
N/A
20%
$10/$30/$60/25%
Select formulary
$60
N/A
$250
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$500
Select formulary
$75
N/A
$250
40%
N/A
40%
N/A
N/A
40%
$15/$35/$70/25%
Select formulary
$75
N/A
$250
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$250
Select formulary
$50
N/A
$200
30%
N/A
30%
N/A
N/A
30%
$15/$35/$70/25%/$250
Select formulary
$60
N/A
$250
20%
N/A
20%
N/A
N/A
20%
$15/$35/$70/25%/$500
Select formulary
$60
N/A
$250
30%
N/A
30%
N/A
N/A
30%
$15/$35/$70/25%/$750
Select formulary
N/A
30%
N/A
30%
N/A
30%
N/A
N/A
30%
Ded/30%
Select formulary
17
Participation requirements
The standard group participation requirement for a
Blue Cross and Blue Shield of Georgia Small Group health
plan is a minimum of 75% of the eligible employees.
Participation requirements are waived beginning
November 15 through December 15 of each year.
BCBSGa may conduct periodic audits to confirm
participation levels.
Small businesses considerations
Rating rule change
Rates will adjust for age at contract renewal
}}
New Hires will be rated based on the age that they were
at the inception of the contract
How rates are calculated
Pre-ACA rate structure
Based on the family tier
Pre-ACA rates
Employee (Single)
Employee/Spouse (Couple)
Employee/Child(ren) (Parent/
Child(ren))
Employee/Spouse/Child(ren) (Family)
$563
$1,170
$928
$1,495
ACA-Compliant Rate Structure
Based on each family member age
}}
Rates will include premiums for all dependents 21
to 26 years of age
}}
Rates will be capped at three dependents under the
age of 21
}}
How will waiting periods be impacted for
small business
BCBSGa will offer the following waiting period options:
}}
— Date of hire.
— First of the month following date of hire.
— One month.
— First of the month following one month.
— Two months.
— First of the month following two months.
— Ninety (90) days.
Existing small groups with waiting periods in excess of 90
days will be mapped to a waiting period that conforms to
the new regulation.
}}
18
Illustrative ACA-compliant rates
Rate
Age
0-20
$196
21
$308
22
$308
23
$308
24
$308
25
$309
26
$315
27
$323
28
$335
29
$345
30
$350
31
$357
32
$364
33
$369
34
$374
35
$376
36
$379
37
$381
38
$384
39
$389
40
$394
41
$401
42
$408
Age
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64+
Rate
$418
$430
$445
$462
$481
$503
$525
$550
$574
$601
$628
$657
$687
$718
$750
$785
$802
$836
$865
$885
$909
$924
Example 1 of ACA Rating Method
ACA-compliant member rates
Age
Rate
Age
Rate
Age
Rate
0-20
$196
35
$376
50
$550
21
$308
36
$379
51
$574
22
$308
37
$381
52
$601
23
$308
38
$384
53
$628
24
$308
39
$389
54
$657
25
$309
40
$394
55
$687
26
$315
41
$401
56
$718
27
$323
42
$408
57
$750
28
$335
43
$418
58
$785
29
$345
44
$430
59
$802
30
$350
45
$445
60
$836
31
$357
46
$462
61
$865
32
$364
47
$481
62
$885
33
$369
48
$503
63
$909
34
$374
49
$525
64+
$924
Member Level Rating Family Premium:
Age
Rate
Joe
53
$628
Spouse
48
$503
Child
18
$196
Child
16
$196
Child
14
$196
Child
12
$0
}
$1,719
Example 2 of ACA-Compliant Composite Premium Rate Structure
ACA-compliant member rates
Employee (Single)
$525
Employee/Spouse (Couple)
$1,050
Employee/Child(ren) (Parent/Child(ren))
$919
Employee/Spouse/Child(ren) (Family)
$1,627
19
20
A full medical wellness offering to help keep
members healthier
BCBSGa offers one of the most comprehensive suites of wellness and clinical care in the industry, because we believe healthy
members are happier, more productive and more successful. So we offer a range of options that balance attractiveness and
cost, letting employers choose the most appropriate and affordable solutions for their needs.
24/7 NurseLine — Members can call anytime to speak to
a registered nurse trained to answer general health
questions, help them understand symptoms, help them
determine the right care at the right time.
}}
Utilization Management — Includes precertification of
medical procedures, imaging services and hospitalization
to authorize care and align medical services with the
member’s benefits.
}}
Imaging Cost and Quality — A member outreach
program designed to lower the costs of expensive
imaging procedures. If the member qualifies they are
contacted about equal-quality, lower cost imaging
alternatives in their area. The program is voluntary and
available in larger metropolitan markets.
}}
Case Management — Offers telephonic and video chat
nursing support following a major hospitalization or
procedure due to illness or injury. Cancer, NICU and
transplant services included. Case Management helps
members maximize medical benefits, arrange
post-discharge care, and community health services.
}}
ComplexCare — The ComplexCare program is for
members with multiple health care issues or those who
may require more frequent medical care. Working with a
personal nurse coach, members receive individualized
care and are able to create a personalized care plan for
greater well-being and self-management of their condition.
}}
Quick Care Options — An initiative to educate members
about non-emergency/avoidable ER visits and steer them
to lower-cost settings with shorter wait times, including
urgent care centers, walk-in doctors’ offices and retail
health clinics. The Quick Care Options program includes
resources to help members make better decisions and
targeted education opportunities after members have an
avoidable ER visit.
}}
LiveHealth Online — the quick and easy way to see a
doctor anywhere you have an Internet connection.
LiveHealth Online is a new communications tool that lets
members talk to doctors through their mobile device or
online by two-way video on a computer. Doctors can
answer questions, make a diagnosis and may prescribe
basic medications.
}}
ConditionCare — For members with chronic conditions
like asthma, diabetes or heart disease, the ConditionCare
disease management program provides targeted
information, guidance and support. With 24/7 access to
health professionals, members are equipped to better
understand and manage their condition, and make
healthier choices for optimal wellness.
}}
Future Moms — The Future Moms program provides
mothers-to-be with personalized support and guidance,
helping them achieve healthier pregnancies and
deliveries. With their own team of obstetric specialists,
expectant members get access to expert information
and direction throughout their pregnancy and
postpartum period.
}}
MyHealth Advantage — Communicates gaps in care and
health savings opportunities to targeted members (via
mailed MyHealth Notes) and gaps in care to their treating
providers (via mailed notices). MyHealth Advantage
analyzes comprehensive health information and suggests
ways members can be healthier and reduce out-of-pocket
expenses. The program aims to reduce health care costs
by increasing member compliance with medical best
practices and improving health care quality.
}}
Behavioral Health UM/CM/DM — Offers immediate and
longer-term mental health management and information
to eligible members.
}}
Employee Assistance Programs — Provides employees
and household members with up to three counseling
sessions with a licensed social worker, counselor or
psychologist to help with issues ranging from stress
management to family and work related concerns. Other
services that are also available include limited financial
and legal consultations at no cost. Employees also get full
access to a specialized website with personal assistance
resources such as an online child care/elder care locator.
}}
21
Offer a well-rounded benefits package from BCBSGa
Dental plan choices to fit your unique needs
With BCBSGa Dental, you have options from essential health
benefit plans to flexible plans with additional options to
build more robust benefits. Employers can also choose from
employer paid and voluntary choices with BCBSGa Dental.
We’ll help you find the right mix of benefits that can have the
best impact on your employees’ health. And no matter which
dental plans you choose, you can count on:
Solid coverage at a good price.
}}
Benefits that make sense for dental health — and
total health.
}}
Lots of participating providers to choose from.
}}
BCBSGa Dental offers a variety of dental plan options that
include or are available with optional pediatric dental
essential health benefits (EHBs).
We offer a choice of several plan types and networks to
fit your needs and budget.
}}
Dental Pediatric EHB Plans. Our medical plans include
the pediatric EHB benefit. We also offer a stand-alone
pediatric EHB plan.
}}
1 Customer service results: 2012 year-to-date results through September 24, 2012.
2 The International Emergency Dental Program is managed by DeCare Dental. DeCare Dental is an independent
company offering dental management services to BCBSGa plans.
3 The national Dental GRID is managed by the GRID Dental Corporation (GDC), a separate company that provides access
to dental networks and services on behalf of BCBSGa Life and Health Insurance Company.
22
With all BCBSGa Dental plans, you and your employees will
enjoy these standard services:
Easy-to-access information. Your employees can go
online any time to get their claims and dental plan
details. Plus, they’ll find helpful materials that promote
dental health.
}}
Expert customer service. We’re committed to giving our
members the best service. Calls are answered quickly
(typically within 30 seconds)1 by reps with dental expertise.
}}
Swift claims payments and data-based benefits. On
average, we pay claims in three days or less. We also track
data from the millions of claims we process each year.
And, we’ve got financial accuracy rates of more than 99%.1
So you can be sure payments are prompt and correct.
}}
International Emergency Dental Program.2 Members who
travel outside of the U.S. have access to emergency
dental services. With one call, we’ll help them find a
credentialed, English-speaking dentist for urgent dental
care. We can even help them with translation services
when they call the dentist’s office. Services members
receive through this program don’t count toward their
annual maximum, if their plan has one.
}}
Dental Prime and Dental Complete
Preventive dental services
Plans with more coverage choices
Preventive dental services are used more than any other
dental services. They can help find dental and other health
problems early on. That’s why most of our Dental Prime
and Dental Complete plans cover routine cleanings, exams
and X-rays 100% at participating dentists. Other preventive
services include:
When we created the new Dental Prime and Dental Complete
plans, we made sure they could be custom fit. That means
lots of choices in coverage, including options for:
Choice of deductibles, annual maximums, and
provider programs.
}}
Orthodontic benefits for kids and adults, or kids only.
}}
Annual maximum carryover, which lets members carry
over some unused benefits to the next year.
}}
Lots of participating dentists to choose from
Dental Prime and Dental Complete members have access
to many participating dentists through the national Dental
GRID.3 The national Dental GRID links dental programs,
including the dental programs of many of the nation’s Blue
plans, and includes dentists in all 50 states — so your
employees can find a participating dentist wherever they
live or visit:
Brush biopsy benefits.* A brush biopsy may help
diagnose oral cancer when combined with a lab analysis
and a surgical biopsy with lab analysis.
}}
Extra services for members who are pregnant or living
with diabetes. We offer an extra cleaning or periodontal
maintenance procedure each year for members who are
pregnant or living with diabetes.
}}
* Brush biopsy benefits paid at the Basic Services level.
Dental Prime members have access to more than
75,000 unique providers (more than 189,000 access
points) nationwide.
}}
Dental Complete members have access to more than
97,000 unique providers (more than 235,000 access
points) nationwide.
}}
23
Dental Prime and Dental Complete plans
Annual
benefit
maximum
Deductible
(per
person/
per family)
waived for
diagnostic
and
preventive
Diagnostic/
preventive
services
(cleanings,
X-rays, exams)
In
Out
In
Out
In
Out
In
Value Complete
GA-1A
$1,000
$50/ $150
100%
100%
80%
80%
80%
80%
Not Covered
Classic Complete
GA-2E
$1,000
$50/ $150
100%
100%
80%
80%
50%
50%
50%
Classic Complete
GA-2F
$1,000
$50/ $150
100%
100%
80%
80%
80%
80%
Classic Complete
GA-2G
$1,000
$50/ $150
100%
100%
80%
80%
80%
Classic Complete
GA-2H
$1,000
$50/ $150
100%
80%
80%
60%
Classic Complete
GA-2J
$1,000
$50/ $150
100%
100%
80%
Classic Complete
GA-2K
$1,000
$50/ $150
100%
100%
Classic Complete
GA-2L
$1,500
$50/ $150
100%
Classic Complete
GA-2M
$1,500
$50/ $150
Classic Complete
GA-2N
$1,500
Classic Complete
GA-2P
Endodontic,
periodontic and
oral surgery
services (root
canal, tooth
extraction, etc.)
Major
services
(crowns,
bridges,
dentures,
etc.)
Orthodontic
coverage
(lifetime
maximum to
match
annual
maximum)
Annual
maximum
carryover
Dental
implants
Network
Out-ofnetwork
reimbursement
Not covered
Not included
Not included
Dental
Complete
90th percentile
Fair Health
50%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
50%
50%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
80%
50%
50%
Not covered
Included
Included
Dental
Complete
90th percentile
Fair Health
80%
60%
50%
50%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
80%
80%
80%
50%
50%
50% children only
Not included
Included
Dental
Complete
90th percentile
Fair Health
80%
80%
80%
80%
50%
50%
Not covered
Not included
Included
Dental
Complete
Maximum allowable
charge (MAC)
100%
80%
80%
50%
50%
50%
50%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
100%
100%
80%
80%
80%
80%
50%
50%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
$25/ $75
100%
100%
80%
80%
80%
80%
50%
50%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
$1,500
$50/ $150
100%
100%
80%
80%
80%
80%
50%
50%
Not covered
Included
Included
Dental
Complete
90th percentile
Fair Healthh
Classic Complete
GA-2Q
$1,500
$50/ $150
100%
80%
80%
60%
80%
60%
50%
50%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
Classic Complete
GA-2R
$1,500
$50/ $150
100%
100%
80%
80%
50%
50%
50%
50%
50% children only
Not included
Included
Dental
Complete
90th percentile
Fair Health
Classic Complete
GA-2S
$1,500
$50/ $150
100%
100%
80%
80%
80%
80%
50%
50%
50% children only
Not included
Included
Dental
Complete
90th percentile
Fair Health
Classic Prime
GA-2A
$1,000
$50/ $150
100%
100%
80%
80%
50%
50%
50%
50%
Not covered
Not included
Included
Dental
Prime
90th percentile
Fair Health
Classic Prime
GA-2B
$1,000
$50/ $150
100%
100%
80%
80%
50%
50%
50%
50%
Not covered
Not included
Included
Dental
Prime
Maximum allowable
charge (MAC)
Classic Prime
GA-2C
$1,500
$50/ $150
100%
100%
80%
80%
50%
50%
50%
50%
Not covered
Not included
Included
Dental
Prime
90th percentile
Fair Health
Classic Prime
GA-2D
$1,500
$50/ $150
100%
80%
80%
60%
80%
60%
50%
50%
Not covered
Not included
Included
Dental
Prime
90th percentile
Fair Health
Enhanced Prime
GA-3A
$2,000
$25/ $75
100%
100%
90%
90%
90%
90%
60%
60%
Not covered
Not included
Included
Dental
Prime
90th percentile
Fair Health
Enhanced
Complete GA-3B
$2,000
$50/ $150
100%
100%
90%
90%
90%
90%
60%
60%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
Enhanced
Complete GA-3C
$2,000
$25/ $75
100%
100%
90%
90%
90%
90%
60%
60%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
Enhanced
Complete GA-3D
$2,000
$50/ $150
100%
100%
90%
90%
90%
90%
60%
60%
Not covered
Included
Included
Dental
Complete
90th percentile
Fair Health
Enhanced
Complete GA-3E
$2,000
$50/ $150
100%
100%
90%
90%
90%
90%
60%
60%
50% adults
and children
Not included
Included
Dental
Complete
90th percentile
Fair Health
Enhanced
Complete GA-3F
$2,000
$50/ $150
100%
100%
90%
90%
90%
90%
60%
60%
50% children only
Not included
Included
Dental
Complete
90th percentile
Fair Health
Plan Name
Basic
services
(filings)
Out
The above is a summary. See the Certificate of Coverage with the Schedule of Benefits and any riders associated with the plan for complete coverage details
and related terms and conditions.
24
Dental Prime and Dental Complete plans (con’t)
Annual
benefit
maximum
Deductible
(per
person/
per family)
waived for
diagnostic
and
preventive
Diagnostic/
preventive
services
(cleanings,
X-rays, exams)
In
Out
In
Out
In
Out
In
Voluntary
Complete GA-4A
$1,000
$50/ $150
100%
100%
80%
80%
50%
50%
Voluntary
Complete GA-4B
$1,000
$50/ $150
100%
80%
80%
80%
50%
Voluntary
Complete GA-4C
$1,500
$50/ $150
100%
100%
80%
80%
50%
Plan Name
Endodontic,
periodontic and
oral surgery
services (root
canal, tooth
extraction, etc.)
Basic
services
(filings)
Major
services
(crowns,
bridges,
dentures,
etc.)
Out
Orthodontic
coverage
(lifetime
maximum to
match
annual
maximum)
Annual
maximum
carryover
Dental
implants
Network
Out-ofnetwork
reimbursement
50%
50%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
50%
50%
50%
Not covered
Not included
Included
Dental
Complete
Maximum allowable
charge (MAC)
50%
50%
50%
Not covered
Not included
Included
Dental
Complete
90th percentile
Fair Health
The above is a summary. See the Certificate of Coverage with the Schedule of Benefits and any riders associated with the plan for complete coverage details
and related terms and conditions.
Stand-alone Dental Pediatric and Family EHB plans
A stand-alone pediatric dental plan may be added to your dental or medical plan if it does not currently include pediatric EHB. This will allow you to be in compliance
with the ACA, and will provide your employee’s children with valuable dental benefits they need to stay healthy. We also offer adult plans that have annual maximums
of $750 or $1,000. These plans can be combined with our pediatric EHB plans to create a family plan. Family plans offer several advantages:
We will not charge for more than three children.
Families will not be charged more than two times the out-of-pocket maximum, regardless of how many children they have.
}}When you purchase BCBSGa Dental Family Enhanced coverage, it comes with a cosmetic orthodontia benefit. The lifetime
maximum for this benefit is $1,000.
}}
}}
When members see providers who participate in Dental Prime, there are no annual maximums. And out-of-pocket costs are limited to $700 a year.
Family and Family Enhanced plans include the dental pediatric EHB benefits.
Plan name
Dental pediatric
Dental family
Dental family
enhanced
Diagnostic
and preventive
services
(cleanings,
exams and
X-rays)
Annual
maximum
Annual outof-pocket
maximum*
combined
In
Out
In
Out
In
Out
In
Out
In
Out
In
Out
In
Out
In
Out
$50 (applies
to all)
None
None
$350*
None
100%
70%
60%
50%
50%
50%
50%
50%
50%
50%
None
None
None
None
$350*
None
100%
70%
60%
50%
50%
50%
50%
50%
50%
50%
None
None
None
None
100%
50%
50%
25%
30%
15%
30%
15%
Not covered
$350*
None
100%
80%
80%
60%
80%
50%
50%
50%
50%
None
None
100%
50%
80%
40%
50%
25%
50%
25%
Not covered
Benefit age
range
Deductible
Pediatric benefits
through age 18
Pediatric benefits
through age 18
$50 (applies
to all)
Adult benefits
19+
$50 (applies
to all)
Pediatric benefits
through age 18
$25 (applies
to all)
Adult benefits
19+
$50 (applies
to all)
$750
None
None
$1,000
Basic
services
(fillings)
Endodontic/
periodontal/
oral surgery
Major
services
(crowns)
Medically
necessary
orthodontia
Medically
necessary
orthodontia
lifetime
maximum
50%
n/a
None
None
n/a
* Per child, up to two children per family.
FFM States no longer allowing Stand-Alone Pediatric Only on the SHOP exchange.
25
Get vision coverage and see increased productivity
Vision plans can play a role in managing the overall health and well-being of your employees. It’s been shown that regular eye
exams and wearing corrective eyewear when needed can greatly decrease the risk of more serious, long-term eye diseases and
can even result in early detection of other health conditions1 — increasing your employees’ productivity and performance. You
get the picture, and so do we. That’s why we’ve created our Blue View VisionSM plans with multiple options to best suit your
employees’ needs.
Blue View VisionSM features:
Powerful, two-way communication between eye care
and health care providers — With Blue View Vision,
network eye care providers can now see data relevant to
their patient’s eye health -- including patient summaries,
diagnoses, lab results, prescriptions and care alerts. And
they, in turn, can share member eye health information
with other network providers. So when any network
doctor, eye doctor or nurse care manager pulls up the
health history, each one understands the member’s whole
health better. So they can give better, more holistic care.
In fact, in a recent survey of vision providers, nearly 100%
responded that clinical coordination of vision and medical
will lead to improved employee health.2
}}
A broad, convenient, national network — The Blue View
Vision network has over 30,000 private practice doctors
and more than 25,000 locations, including the nation’s
leading retail stores like LensCrafters®, Pearle Vision®,
Sears OpticalSM, Target Optical® and JCPenney® Optical.
These retail locations offer convenient evening and
weekend hours, allowing your employees to schedule
appointments outside their normal work day. Members
can also use their in-network benefits at 1-800 CONTACTS.
}}
Blue View Vision Plans
Option
Copay
Exam/Lenses
Frame/
Contact
Allowance
Frequency
Routine Eye Exam
Eyeglass Frames
Eyeglass Lenses
Contacts*
A1
$10/$0
$130/$130
Once per calendar year
Once per calendar year
Once per calendar year
Once per calendar year
A2
$15/$0
$120/$115
Once per calendar year
Once per calendar year
Once per calendar year
Once per calendar year
A3
$10/$10
$130/$130
Once per calendar year
Once per calendar year
Once per calendar year
Once per calendar year
A4
$10/$20
$130/$130
Once per calendar year
Once per calendar year
Once per calendar year
Once per calendar year
A5
$20/$20
$130/$130
Once per calendar year
Once per calendar year
Once per calendar year
Once per calendar year
B1
$10/$0
$130/$130
Once per calendar year
Once every other calendar year
Once per calendar year
Once per calendar year
B2
$10/$20
$100/$100
Once per calendar year
Once every other calendar year
Once per calendar year
Once per calendar year
B3
$10/$20
$130/$130
Once per calendar year
Once every other calendar year
Once per calendar year
Once per calendar year
B4
$20/$20
$130/$130
Once per calendar year
Once every other calendar year
Once per calendar year
Once per calendar year
C1
$10/$0
$130/$130
Once per calendar year
Once every other calendar year Once every other calendar year Once every other calendar year
C2
$10/$20
$130/$130
Once per calendar year
Once every other calendar year Once every other calendar year Once every other calendar year
C3
$20/$20
$130/$130
Once per calendar year
Once every other calendar year Once every other calendar year Once every other calendar year
C4
$25/$0
$120/$115
Once per calendar year
Once every other calendar year Once every other calendar year Once every other calendar year
MO1
Not covered/$10
$130/$130
Not covered
Once per calendar year
Once per calendar year
Once per calendar year
MO2
Not covered/$10
$130/$130
Not covered
Once every other calendar year
Once per calendar year
Once per calendar year
*Non-elective contacts covered in full.
All product offerings are subject to regulatory review and approval.
1 American Optometric Association, aoanet.org.
2 Blue Cross and Blue Shield of Georgia Provider Survey 2012.
3 Discounts (lowered costs) do not apply on frames for which a manufacturer has imposed a no-discount policy.
26
“Add ons” at no additional charge — Factory scratch
coating on eyeglass lenses included at no additional cost,
and Transitions® and polycarbonate lenses for kids under
19 years old can be added at no additional cost.
}}
Negotiated rates for other “add ons” — Includes
Transitions lenses for adults at a fixed price of $75, as well
as tiered pricing for premium progressive lenses and
premium anti-reflective coatings, which limits members’
out-of-pocket costs.
}}
Value-added savings:
}}
— 40% off additional pairs of glasses.
— 20% off any balance over the frame allowance.3
— 15% off additional conventional contact lenses.
— 20% off other upgrades and eyewear accessories
to help keep more money in our members pockets.
And members can get a lowered cost on LASIK laser vision
corrective surgery through our SpecialOffersSM program.
}}Customer care — Our award-winning Customer Care
center has live representatives available seven days a week.
We offer longer evening hours and an afterhours IVR system
so members can reach us at any time with their questions.
Connecting the dots — Only BCBSGa leads the way in
helping eye doctors and primary care doctors work together
so they can share information — all through one company.
This approach makes the eye exam far less routine. If an
eye doctor finds a high-risk health problem such as
diabetes or high blood pressure during a routine eye exam,
they can share that information with the member’s primary
care doctor. The information is tracked in a digital health
record so our members can get the follow-up care and
support they need.
}}
27
Get life and disability insurance from Greater Georgia Life Insurance Company … and share the
benefits of your employees’ security
Life insurance is an easy, inexpensive way to help your employees improve their families’ financial security.
Our insurance products include:
Basic term life
}}
Dependent life
}}
Optional life
}}
Voluntary life
}}
Short-term disability
}}
Voluntary short-term disability
}}
Long-term disability
}}
Voluntary long-term disability
}}
Greater Georgia Life Insurance Company offers:
Integration — Short-term disability coverage integrates with our ConditionCare and/or Future Moms programs — providing
additional guidance, resources and health management for employees who are pregnant or have chronic health conditions.
}}
Strength — We have over 50 years of skill and know-how in the industry, and an A.M. Best financial rating of “A (Excellent).”
}}
6 Members who have an BCBSGa health plan and with a diagnosis of asthma, coronary obstructive pulmonary disease, coronary artery disease,
congestive heart failure and diabetes.
7 Claims handled in an average of 6.9 business days from claim receipt in 2012.
Why Life Insurance from Greater Georgia Life Insurance Company?
Rated “A (Excellent)” for financial strength by A.M. Best Company.
}}
Life claim turnaround time is among the fastest in the industry — usually within
two days.7
}}
28
Extra Features — Our plans offer more than just a benefit check — we include support services to help employees get
back to their normal life.
}}
— Resource Advisor gives employees counseling and consultations regarding emotional, financial and legal concerns,
as well as identity theft prevention and recovery services.
— Employees and family members traveling 100 or more miles from home have access to travel assistance services.
This program includes emergency medical assistance and transportation (up to $1M), travel services and
pre-departure information for business or personal travel.
— New mothers with approved short-term disability claims can get eight weeks of personalized parent coaching and
support through Newborn and Parenting Resources to help them transition back to work while balancing motherhood,
family duties and work life.
29
Exclusions and limitations
Request a copy of the Combined Evidence of
Coverage/Certificate for comprehensive details on
covered services, limitations and exclusions.
l. Contact reflex analysis.
m. Bioenergial synchronization technique (BEST).
n. Iridology-study of the iris.
o. Auditory integration therapy (AIT).
p. Colonic irrigation.
q. Magnetic innervation therapy.
r. Electromagnetic therapy.
s. Neurofeedback/Biofeedback.
All Exclusions and Limitations are subject to
regulatory review and approval.
1. Acts of War, Disasters, or Nuclear Accidents.
In the event of a major disaster, epidemic, war, or other
event beyond BCBSGa’s control, BCBSGa will make a good
faith effort to give you Covered Services. BCBSGa will not be
responsible for any delay or failure to give services due to
lack of available facilities or staff. Benefits will not be given
for any illness or injury that is a result of war, service in the
armed forces, a nuclear explosion, nuclear accident, release
of nuclear energy, a riot, or civil disobedience.
2. Administrative Charges.
a. Charges to complete claim forms.
b. Charges to get medical records or reports.
c. Membership, administrative, or access fees charged by
Doctors or other Providers. Examples include, but are
not limited to, fees for educational brochures or calling
you to give you test results.
3. Alternative/Complementary Medicine.
Services or supplies for alternative or complementary
medicine. This includes, but is not limited to:
a. Acupuncture.
b. Holistic medicine.
c. Homeopathic medicine.
d. Hypnosis.
e. Aroma therapy.
f. Massage and massage therapy.
g. Reiki therapy.
h. Herbal, vitamin or dietary products or therapies.
i. Naturopathy.
j. Thermography.
k. Orthomolecular therapy.
30
4. Before Effective Date or After Termination Date.
Charges for care you get before your Effective Date or after
your coverage ends, except as written in this Plan.
5. Charges Over the Maximum Allowed Amount.
Charges over the Maximum Allowed Amount for
Covered Services.
6. Charges Not Supported by Medical Records.
Charges for services not described in your medical records.
7. Complications of Non-Covered Services.
Care for problems directly related to a service that is not
covered by this Plan. Directly related means that the care
took place as a direct result of the non-Covered Service and
would not have taken place without the non-Covered Service.
8. Cosmetic Services.
Treatments, services, Prescription drugs, equipment, or
supplies given for cosmetic services. Cosmetic services are
meant to preserve, change, or improve how you look or are
given for psychiatric, psychological, or social reasons. No
benefits are available for surgery or treatments to change
the texture or look of your skin or to change the size, shape
or look of facial or body features (such as your nose, eyes,
ears, cheeks, chin, chest or breasts).
This Exclusion does not apply to “Reconstructive Surgery” as
stated under “Surgery” in the “What’s Covered” section.
9. Crime.
Treatment of an injury or illness that results from a crime you
committed, or tried to commit. This Exclusion does not apply
if you were the victim of a crime, including domestic violence.
10. Custodial Care.
Custodial Care, convalescent care or rest cures. This
Exclusion does not apply to Hospice services.
11. Dental.
Treatment Dental treatment, except as
listed below.
Excluded treatment includes but is not limited to preventive
care and fluoride treatments; dental X-rays, supplies,
appliances and all associated costs; and diagnosis and
treatment for the teeth, jaw or gums such as:
Removing, restoring, or replacing teeth.
}}
Medical care or surgery for dental problems (unless listed
as a Covered Service in this Booklet).
}}
Services to help dental clinical outcomes.
}}
Dental treatment for injuries that are a result of biting or
chewing is also excluded.
This Exclusion does not apply to services that we must cover
by law or to the “Dental Services” described in the “What’s
Covered” section of this Booklet.
12. Educational Services.
Services or supplies for teaching, vocational, or self-training
purposes, except as listed in this Booklet.
13. Experimental or Investigational Services.
Services or supplies that are Experimental/Investigational
as defined in the “Definitions” section of this Booklet. Except
as stated under “Clinical Trials” in the “What’s Covered”
section, this exclusion also applies to services related to
Experimental/Investigational services, whether you get them
before, during, or after you get the Experimental/
Investigational service or supply.
The fact that a service or supply is the only available
treatment will not make it Covered Service if it is
Experimental/Investigational.
14. Eyeglasses and Contact Lenses.
Eyeglasses and contact lenses to correct your eyesight
unless listed as covered in this Booklet. This Exclusion does
not apply to lenses needed after a covered eye surgery.
15. Eye Exercises.
Orthoptics and vision therapy.
16. Eye Surgery.
Eye surgery to fix errors of refraction, such as near
sightedness. This includes, but is not limited to, LASIK,
radial keratotomy or keratomileusis, and excimer laser
refractive keratectomy.
17. Family Members.
Services prescribed, ordered, referred by or given by a
member of your immediate family, including your spouse,
child, brother, sister, parent, in-law, or self.
18. Foot Care.
Routine foot care unless Medically Necessary. This Exclusion
applies to cutting or removing corns and calluses; trimming
nails; cleaning and preventive foot care, including but not
limited to:
a. Cleaning and soaking the feet.
b. Applying skin creams to care for skin tone.
c. Other services that are given when there is not an illness,
injury or symptom involving the foot.
19. Foot Orthotics.
Foot orthotics, orthopedic shoes or footwear or support
items unless used for an illness affecting the lower limbs,
such as severe diabetes.
20. Foot Surgery.
Surgical treatment of flat feet; subluxation of the
foot; weak, strained, unstable feet; tarsalgia;
metatarsalgia; hyperkeratoses.
21. Free Care.
Services you would not have to pay for if you didn’t have
this Plan. This includes, but is not limited to government
programs, services during a jail or prison sentence, services
you get from Workers’ Compensation, and services from
free clinics.
If Workers’ Compensation benefits are not available to you,
this Exclusion does not apply. This Exclusion will apply if you
get the benefits in whole or in part. This Exclusion also
applies whether or not you claim the benefits or
compensation, and whether or not you get payments from
any third party.
22. Health Club Memberships and Fitness Services.
Health club memberships, workout equipment, charges from
a physical fitness or personal trainer, or any other charges
for activities, equipment, or facilities used for physical
fitness, even if ordered by a Doctor. This Exclusion also
applies to health spas.
31
23. Home Care.
a. Services given by registered nurses and other health
workers who are not employees of or working under
an approved arrangement with a Home Health
Care Provider.
b. Private duty nursing.
30. Nutritional or Dietary Supplements.
Nutritional and/or dietary supplements, except as described
in this Booklet or that we must cover by law. This Exclusion
includes, but is not limited to, nutritional formulas and
dietary supplements that you can buy over the counter and
those you can get without a written Prescription or from a
licensed pharmacist.
c. Food, housing, and home delivered meals.
d. Homemaker services, except for the homemaker visits
described in the “What’s Covered” section under
“Home Care” (prenatal and post partum visits) and
under “Hospice.”
24. Infertility Treatment.
Infertility testing, treatment or procedures not specified in
this Booklet.
25. Maintenance Therapy.
Treatment given when no further gains are clear or likely to
occur. Maintenance therapy includes care that helps you
keep your current level of function and prevents loss of that
function, but does not result in any change for the better.
26. Medical Equipment and Supplies.
a. Replacement or repair of purchased or rental equipment
because of misuse, abuse, or loss/theft.
b. Surgical supports, corsets, or articles of clothing unless
needed to recover from surgery or injury.
c. Non-Medically Necessary enhancements to standard
equipment and devices.
31. Out-of-Network Care.
Services from a Provider that is not in BCBSGa’s network.
This does not apply to Emergency Care, Urgent Care, or
Authorized Services.
32. Oral Surgery.
Extraction of teeth, surgery for impacted teeth and other oral
surgeries to treat the teeth or bones and gums directly
supporting the teeth, except as listed in this Booklet.
33. Personal Care and Convenience.
a. Items for personal comfort, convenience, protection,
cleanliness such as air conditioners, humidifiers, water
purifiers, sports helmets, raised toilet seats, and
shower chairs.
b. First aid supplies and other items kept in the home for
general use (bandages, cotton-tipped applicators,
thermometers, petroleum jelly, tape, non-sterile gloves,
heating pads).
c. Home work out or therapy equipment, including
treadmills and home gyms.
d. Pools, whirlpools, spas, or hydrotherapy equipment.
e. Hypoallergenic pillows, mattresses, or waterbeds.
27. Medicare.
Services for which benefits are payable under Medicare Parts
A, B, and/or D, or would have been payable if you had applied
for Parts A and/or B and/or D, except as listed in this Booklet
or as required by the federal law described under “Medicare”
in the “General Provision” section. If you do not enroll in
Medicare Part B, BCBSGa will calculate benefits as if you had
enrolled. You should sign up for Medicare Part B as soon as
possible to avoid large out-of-pocket costs.
28. Missed or Canceled Appointments.
Charges for missed or canceled appointments.
29. Non-Medically Necessary Services.
Services that are not Medically Necessary as defined in the
“Definitions” section of this Booklet.
32
f. Residential, auto, or place of business structural changes
(ramps, lifts, elevator chairs, escalators, elevators, stair
glides, emergency alert equipment, handrails).
34. Private Duty Nursing.
Private Duty Nursing Services.
35. Prosthetics.
Prosthetics for sports or cosmetic purposes.
36. Providers.
Services you get from a non-covered Provider, as defined in
this Booklet. Examples of non-covered Providers include, but
are not limited to, masseurs or masseuses (massage
therapists), physical therapist technicians, and
athletic trainers.
37. Sex Change.
Services and supplies for a sex change and/or the reversal of
a sex change.
38. Sexual Dysfunction.
Services or supplies for male or female sexual problems.
39. Smoking Cessation.
Programs to help you stop smoking.
40. Stand-By.
Charges Stand-by charges of a Doctor or other Provider.
41. Reversal of Elective Sterilization.
42. Surrogate Mother Services.
Services or supplies for a person not covered under this Plan
for a surrogate pregnancy (including, but not limited to, the
bearing of a child by another woman for an infertile couple).
l. For services or supplies combined with any other offer,
coupon or in-store advertisement.
m. For Members through age 18, no benefits are available
for frames not on the BCBSGa formulary.
n. Certain frames in which the manufacturer imposes a no
discount policy.
46. Weight Loss Programs.
Programs, whether or not under medical supervision, unless
listed as covered in this Booklet.
This Exclusion includes, but is not limited to, commercial
weight loss programs (Weight Watchers, Jenny Craig, LA
Weight Loss) and fasting programs.
This Exclusion does not apply to the “Diabetes Management”
or “Preventive Care” benefits or to “Surgery for conditions
caused by obesity” under “Surgery” in the “What’s
Covered” section.
43. Travel Costs.
Mileage, lodging, meals, and other Member-related travel
costs except as described under “Ambulance Services” in the
“What’s Covered” section of this Booklet.
44. Vein Treatment.
Treatment of varicose veins or telangiectatic dermal veins
(spider veins) by any method (including sclerotherapy or
other surgeries) for cosmetic purposes.
45. Vision Services.
a. Vision services for Members age 19 or older, unless listed
as covered in this Booklet.
b. Eyeglass lenses, frames, or contact lenses for Members
age 19 and older, unless listed as covered in this Booklet.
c. Safety glasses and accompanying frames.
d. For two pairs of glasses in lieu of bifocals.
e. Plano lenses (lenses that have no refractive power)
f. Lost or broken lenses or frames if the Member has already
received benefits during a Benefit Period.
g. Vision services not listed as covered in this Booklet.
h. Cosmetic lenses or options.
i. Blended lenses.
j. Oversize lenses.
k. Sunglasses and accompanying frames.
33
34
35
Make the Affordable Care Act
work better for you.
Contact your broker or your BCBSGa representative
for more information about our plans.
Life and Disability products are underwritten by Greater Georgia Life Insurance Company (GGL) using the trade name Anthem Life. Blue Cross and Blue Shield of Georgia, Inc., Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. and GGL are independent licensees of the
Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered trademarks of the Blue Cross and Blue Shield Association.