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A Summary of Georgia Health Insurance Benefits

Summary of Benefits

Summary of Benefits	In-Network
All care must be received from or coordinated through your Primary Care Physician. A Participant has Direct Access to some specified In-Network Providers without a Primary Care Physician Referral. Such Providers include a gynecologist for obstetrical or gynecological-related conditions, a dermatologist; and an optometrist or ophthalmologist for medical conditions only.
Lifetime Maximum Benefits (including Mental Health Care & Substance Abuse Treatment)	$2,000,000
Percentage Payable (Unless Otherwise Specified) All payments are based on Eligible Charges and negotiated arrangements. The Program Pays The Participant Pays The percentage payable after the Out-of-Pocket Limit is met	90% 10% 100%
Calendar Year Deductible Under Family Coverage, a Participant cannot meet more than the Individual Deductible Individual Family	$200 $400
Out-of-Pocket Limit Per Calendar Year (in addition to the Copayment) Under Family Coverage, a Participant cannot meet more than the Individual Out-of-Pocket Limit Individual Family	1,000 $2,000
Hospital Inpatient Services (subject to the Deductible) Room and Board (Semi-Private or ICU/CCU) Hospital Services and Supplies (x-ray, lab, anesthesia, etc.) Physician Services (Maternity Delivery) - not subject to Deductible Physician Services (Well Newborn Care) Physician Services (surgeon, anesthesiologist, radiologist, pathologist, etc.)	90% 90% 100% 100% 90%
Outpatient Hospital Services (subject to the Deductible) Outpatient Surgery Facility, etc. Outpatient Lab, X-ray and Anesthesia Services Outpatient Physician Services (surgeon, anesthesiologist, radiologist, pathologist, etc.)	90% 90% 90%
Emergency Room Copayment Life-threatening medical conditions or serious Accidental Injuries. Initial services rendered for the onset of symptoms for a life-threatening medical condition or serious Accidental Injury which requires immediate medical care. A Medical Emergency is a condition of recent onset and sufficient severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or Injury is of such a nature that failure to obtain immediate medical care could place his or her life in danger or serious harm. The emergency room Copayment is waived if admitted to the Hospital through the emergency room. Coverage is provided on a 24-hour basis for these services. Follow-up care must be coordinated through your Primary Care Physician. Primary Care Physician notification, if not completed prior to emergency room visit, must occur within 48 hours of seeking emergency room care.	$100
Non-emergency use of the emergency room	Not Covered
Inpatient Mental Health Care and Substance Abuse Treatment Days/Visits Maximum Per Calendar Year Hospital Inpatient Services Physician Hospital Services	30 90% 90%
Inpatient Substance Abuse Detoxification Percentage Payable Maximum Days Per Calendar Year (part of the 30 days per calendar year Inpatient Mental Health Care benefit)	90% 3 Episodes
Outpatient Mental Health Care and Substance Abuse Treatment Maximum Visits Per Calendar Year Per Visit Copayment	25 $25
Primary Care Physician Copayment, per office visit Including Outpatient Surgery in Physician's office	$20
After-Hours Primary Care Physician Copayment	$25
Specialist Physician Copayment, per office visit (Primary Care Physician Referral Needed) Allergy office visits, shots, serum, testing Dermatologist Services (PCP Referral not required) Maternity Care Visits (first visit only)(PCP Referral not required) Outpatient Surgery in Physician's office Physical/Occupational Therapy: 40 visits per calendar year Speech Therapy: 40 visits per calendar year Vision Care Services (excluding routine vision Care) (PCP Referral not required) Services must be provided by a network ophthalmologist or optometrist for the treatment of acute conditions only	$25
Outpatient Acute Short-Term Rehabilitation Services Maximum Visits Per Calendar Year Per Visit Copayment	40 $25
Chiropractic Rider (PCP Referral not required) Maximum Visits Per Calendar Year (Spinal Manipulation, one treatment per day.) Per Visit Copayment	20 $25
Preventive Health Care in the Physician's Office Copayment, per office visit The following services may be performed by a Primary Care Physician or Specialist Physician. Primary Care Physician Copayment, per office visit Specialist Physician Copayment, per office visit Preventive Services for Children Age 5 and Under Periodic Health Assessments Development assessment of the child Age appropriate immunizations Laboratory testing Preventive Services for Children Over Age 5 and Adults Services include, but are not limited to: Periodic Health Assessments Immunizations Flu Injections Preventive Services for Women Annual Gynecological Exam (PCP Referral not required) Mammography (the program pays 100% after the Copayment) Pap Smear Chlamydia Screening Ovarian Surveillance Colorectal Screening Preventive Services for Men Prostate Screening Colorectal Screening	$20 $25
Ambulance Services (when Medically Necessary)	100%
Durable Medical Equipment (when Medically Necessary)	100%
Home Health Care Services Visits Per Calendar Year	100% 120
Hospice Care Services (subject to the Deductible)	100%
Radiation Therapy, Chemotherapy	100%
Skilled Nursing Facility (subject to the Deductible) Days Per Calendar Year (prior approval required)	90% 120
Transplant Services (subject to the Deductible)	90%
Retail Prescription Drugs Copayment (30-day supply from participating pharmacies) Generic in Formulary, per prescription Brand Name in Formulary, per prescription Brand Name not in Formulary, per prescription Maintenance Prescription Drugs Copayment (90-day supply from participating pharmacies) Generic in Formulary, per prescription Brand Name in Formulary, per prescription Brand Name not in Formulary, per prescription	$10 $25 $50 $20 $50 $100
Note: Covered Services available under Home Health Care do NOT reduce outpatient benefits available under the Physical Therapy section shown in this Contract. A limited number of Prescription Drugs require pre-authorization for Medical Necessity. If pre-authorization is not approved, then the designated drug will not be eligible for coverage. To determine if a drug requires pre-authorization, please call Customer Service. Prescriptions are not covered when written by an Out-of-Network Provider.

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