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Blue Cross Blue Shield of Georgia PPO Plan
or consider a Short-Term
Medical Plan
Welcome to First Benefits' Individual Plans featuring
the Blue Choice PPO Plan from Blue Cross Blue Shield of Georgia.
Please read the Plan Summary, see the current monthly
premiums and if the benefits are right for you, then download the Instructions
and the Application. Then you may call our Customer
Service to assist you with the application.
Plan Summary
BlueChoice PPO for Individuals offers six plan options
with different deductible amounts. The higher the annual deductible,
the lower the member's monthly premium will be.
Listed below are the six BlueChoice PPO plans and the
corresponding deductible amounts. Also included is the Plan's annual
out-of-pocket limit, which is the maximum out-of-pocket money a member
must pay in a year's time, after his/her annual deductible is satisfied.
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Plan 1 |
Plan 2 |
Plan 3 |
Plan 4 |
| Deductible |
$250 |
$500 |
$1,000 |
$1,500 |
Maximum
out-of-pocket |
$2,000 |
$2,000 |
$2,000 |
$2,000 |
Plans 1 and 2 have an in-network office copayment feature.
When a member visits a preferred or participating physician, he or she
will pay just a $20 copayment. On the other deductible plans, office
visits and all other services are subject to deductible and coinsurance.
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Instructions and Application
Product Description:
BlueChoice PPO offers its members low monthly health
benefit costs and low out-of-pocket costs through an extensive network
of hospitals and physicians. BlueChoice PPO members also retain the
freedom to use a non-network physician at a reduced level of benefits.
When a BlueChoice PPO member uses a network physician,
he or she pays only a minimal copayment for each office visit. Should
the member choose a physician who is not part of the BlueChoice
PPO network, the visit is subject to the member's deductible and
coinsurance. Standard benefits include adult and well-child preventive
care designed to keep both the members and his/her covered dependents
healthy.
If a member or covered dependent requires hospitalization,
BlueChoice PPO provides a full range of benefits that offer financial
protection from the cost of today's hospital care. By choosing a network
hospital, a member minimizes both the administrative hassle and his/her
share of the hospital bill. However, in the event he or she elects to
use a non-network hospital, his/her out-of-pocket costs will be higher
and he or she may have to do more paperwork.
Blue Cross and Blue Shield of Georgia offers its members
a variety of different plan designs. Options include copayments as low
as $20, coinsurance amounts for 80/60 and deductibles from $250 to $5,000.
No matter which plan design a member chooses, BlueChoice PPO offers
$2,000,000 in lifetime benefits.
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Instructions and Application
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Frequently Asked Questions:
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Instructions and Application
Questions and Answers:
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1.
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Can
a member get coverage for just his/her children if he or she
wants to? |
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Yes. We realize no two families' insurance
needs are exactly alike. If a member needs child-only coverage,
it's available, in the same benefit amount as adults. By
the same token, a member can also get coverage for just
himself or herself, his/her spouse, his/her dependents,
any children for whom he or she assumes legal guardianship
such as foster children, or any combination of the above.
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Top of page
| Download
Instructions and Application
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2.
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Is
there a waiting period for any pre-existing conditions?
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Yes. Preexisting conditions are not covered
for 12 months from the effective date of the member contract.
Naturally, there's no waiting period for new conditions
that may occur after a member's contract effective date.
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Top of page
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Instructions and Application
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3.
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What
services are covered vs. not covered under the preferred provider's
office visit copayment? |
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If a member purchases or has a $250 or $500
deductible plan, his/her contract includes a provision for
an office visit copayment for preferred providers.
The following services will be covered under
the copayment:
- Physician office charges
- Adult preventive health assessment (a
periodic examination based on established medical guidelines
- Routine well-baby examinations (as recommended
by the American Pediatric Association)
- Immunizations (vaccinations administered
to children)
- Annual gynecological examination
- Mammograms, Pap tests and prostate screenings
- Treatment of accidental injuries
- Diagnostic X-rays and laboratory tests
when provided and billed by the treating physician
- Annual flu vaccinations
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Instructions and Application
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4.
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What
does a member pay for covered services? |
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There are four types of payment for which a member may
be responsible.
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1. |
Copayment - A fixed amount
that a member pays for selected services. When a member
uses a network provider, services covered by a copayment
are usually not subject to the calendar year deductible
or coinsurance. ($250 and $500 deductible plans only.)
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Note: Plans 1 and 2 offer
the in-network copayment feature. Copayment amounts
do not accumulate toward meeting the calendar year deductible,
coinsurance or out-of-pocket maximum. |
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2. |
Deductible - A preset amount
of covered medical expenses that a member must pay each
calendar year before Blue Cross and Blue Shield of Georgia
pays benefits. |
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3. |
Coinsurance - A specified
percentage that a member must pay for covered services
in addition to his/her member calendar year deductible. |
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4. |
Out-of-Pocket Expense Maximum
- The total amount of covered medical expenses a member
must pay each calendar year after the calendar year
deductible is met. Services with the office copayment
feature are not subject to the deductible, unless specified
in a member's contract. |
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Top of page
| Download
Instructions and Application
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5.
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What
services are subject to the deductible and coinsurance?
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- All covered services if a member's contract
does not include a provision for copayments
- Services not covered under the copayment
feature
- Services received from a non-preferred
provider
- Diagnostic services obtained at a hospital
as an outpatient
- Lab/X-ray billed by outside facility
other than a member's preferred provider
- Allergy shots
- Steroid injections for the treatment
of joint disease or injury
- Outpatient surgery
- In-office surgery
- Physical therapy
- Refractory eye exams
- Invasive procedures
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| Download
Instructions and Application
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6.
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How
much will a member pay for his/her prescriptions and where
can prescription be filled? |
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A member pays either the participating provider
charge or standard copayment for his/her medication. If
a member's prescriptions are subject to a deductible and
coinsurance, the member must meet his/her deductible before
Blue Cross and Blue Shield of Georgia will reimburse him/her
at the contracted benefit amount.
An extensive number of chain and individually
owned pharmacies contract with Blue Cross and Blue Shield
of Georgia to offer BlueChoice PPO members a pharmacy benefit.
These participating pharmacies will file claims for our
members and charge a discounted rate for covered prescription
drugs. These two features will make the member's visit to
a participating pharmacy more convenient and less expensive.
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Top of page
| Download
Instructions and Application
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7.
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Can
a member go to any hospital if he/she needs to be hospitalized?
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In most cases, a member and his/her physician
plan in advance where he/she will go, what needs to be done
and how long he/she will be in the hospital.
Prior to a member's admission, Blue Cross
and Blue Shield of Georgia must pre-approve all in-network
or out-of-network hospital admissions and outpatient surgical
procedures. Emergency or maternity admissions must be certified
within 48 hours of admission.
It is a member's responsibility to make
sure his/her provider calls to obtain pre-approval. A member
is free to choose any hospital that he/she or his/her physician
determines is best for him/her. If a member selects a preferred
or participating hospital, covered services will be paid
at the higher in-network rate, the hospital will file claims
for the member and he/she will not be billed for amounts
over and above the usual, customary and reasonable rates.
A list of network hospitals can be found in our printed
Provider Directory/Member Guide as well as in our on-line
listing of network
providers.
If a member selects a non-preferred or non-participating
hospital, covered services will be paid at the lower out-of-network
rate, and the member will pay more out-of-pocket. Also,
a member may be asked to pay for some services up front,
he/she may have to file his/her own claims and he/she may
be balance-billed if charges exceed the amount allowed by
Blue Cross and Blue Shield of Georgia. Balance-billed means
the provider will bill the member for charges above the
amount reimbursed by Blue Cross and Blue Shield of Georgia
or the difference between billed charges and the amount
paid.
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8.
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Will
a member's coverage be reduced if he/she goes to a non-preferred
hospital in an emergency? |
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No. If
a life-threatening illness or injury occurs, the member should
go to the nearest hospital He/She will be covered at the higher
in-network rate. |
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Top of page
| Download
Instructions and Application
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9.
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How
does the BlueChoice Vision Discount Program work? |
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A member can visit any participating LensCrafters
in Georgia (excluding LensCrafters Optics) or any one in
our network of independent BlueChoice Vision optometrist
to save on eye exams and a broad selection of eyewear. A
complete list of these providers will be made available
upon your acceptance of converge in the Provider Directory/Member
Guide.
Savings available from each type of provider
are:
LensCrafters:
- Three-tiered selection of eyeglasses
through preset package prices 30 % off the regular retail
price of any non-BlueChoice Vision package eyeglasses
- Contact lenses at low fixed prices
- Eye exams at low fixed prices by independent
doctors of optometry located next to LensCrafters
- 25% off the regular price of non-prescription
sunglasses
Independent BlueChoice Vision Optometrists:
- 30% off the regular retail price of any
eyeglasses
- Contact lenses at low fixed prices
- Eye exams at low fixed prices
- 25% off the regular retail price on nonprescription
sunglasses
Note: This is not an insured benefit-it
is a discount program.
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Top of page
| Download
Instructions and Application
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10.
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How
does the Complementary Medicine Program work? |
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Blue Cross Blue Shield of Georgia has contracted
with a statewide network of complementary medicine practitioners
to offer its members a 20% savings on several different
types of complementary medicine, including:
- Acupuncture
- Chiropractic
- Mind-Body Medicine
- Therapeutic Massage
To take advantage of the program, members
can visit any of the providers included in the complementary
medicine program network. A complete list of these providers
will be provided upon your acceptance in the Provider Directory/Member
Guide.
Note: This is not an insured benefit-it
is a discount program.
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Top of page
| Download
Instructions and Application
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11.
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What
is the BlueCard PPO Program? |
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BlueCard PPO is a network partnership with
all of the Blue Cross and Blue Shield Plans across the country.
This nationwide partnership provides health care coverage
for a member anywhere in the United States.
The BlueCard PPO program links each participating
provider directly to all the Blue Cross and Blue Shield
Plans. This extensive network delivers member claim information
electronically from health care providers to Blue Plans
anywhere in the U.S.
The program also offers members access to
international inpatient hospital coverage.
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Top of page
| Download
Instructions and Application
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12.
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Who
should I contact to order supplies, applications or to check
on the status of an application that I have submitted for
processing ? |
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For Customer
Service, contact us at the following address and phone number:
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Atlanta and North Georgia,
contact:
Mark
Lane, MBA
First Benefits, Inc. - Atlanta
3827 Roswell Road, Bld. 100
Marietta, GA 30062
mark@FirstBenefits.com
(770)
643-4800
(770) 643-4870 fax
(800) 825-7605
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South of Atlanta, Georgia
contact:
Roscoe
Douglas, CLU, RHU
First Benefits, Inc. - Macon, GA
3783 Vineville Avenue
Macon, GA 31204
roscoe@FirstBenefits.com
(478)
475-9555
(478) 475-5222 fax
(800) 715-7021
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top of page
| Download
Instructions and Application
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