Blue Cross Blue Shield of Georgia Blue Value Select 1000 Plan Information

Plan Name: Blue Value Select 1000

Plan Type: PPO

Physician Choice: You choose specialist(s)

Calendar Year Deductible In-network: $1000

Calendar Year Deductible Out-of-network: $2000

Coinsurance In-network: Plan pays 80%

Coinsurance Out-of-network: Plan pays 60%

Calendar Year Coinsurance Maximum In-network: $2000

Calendar Year Coinsurance Maximum Out-of-network: No limit

Physician Office Visit In-network: $30

Physician Office Visit Out-of-network: Plan pays 60% after deductible is met

Preventive Care Adults In-network: $30

Preventive Care Adults Out-of-network: Plan pays 60%

Preventive Care Children In-network: $30

Preventive Care Children Out-of-network: Plan pays 60%

Lab/X-ray, Surgery, Radiation, Anesthesia In-network: Plan pays 80%

Lab/X-ray, Surgery, Radiation, Anesthesia Out-of-network: Plan pays 60%

Outpatient Care In-network: Plan pays 80%

Outpatient Care Out-of-network: Plan pays 60%

Maternity Physician In-network: Plan pays 80%

Maternity Physician Out-of-network: Plan pays 60%

Hospital Inpatient Services In-network: Plan pays 80%

Hospital Inpatient Services Out-of-network: Plan pays 60%

Physical/Occupational Therapy, Chiropractic In-network: Plan pays 80%, 30 visits per specialty per year

Physical/Occupational Therapy, Chiropractic Out-of-network: Plan pays 60%, per specialty per year

Behavioral Health/Substance Abuse Hospital Inpatient: $100 per day; $3000 calendar year maximum; $10,000 lifetime maximum

Behavioral Health/Substance Abuse Outpatient: Not covered

Emergency Room Copayment: $150

Emergency Room Medical Emergency or Accident: Plan pays 100% after $150 copay; Not subject to calendar year deductible

Emergency Room Non-Medical Emergency or Non-Serious Accidental Injury: Plan pays 80% in-network; Plan pays 60% out-of-network

Prescription Drugs: Calendar Year Prescription Drug Deductible: $200; Generic Formulary: $15; Brand Formulary: $30; Non-Formulary: $45

Other Blue Cross Blue Shield of Georgia health insurance plans:

• Blue Value 10000
• HSA Compatible HDHP PPO 2600 Ded 80 Coin
• Blue Value 5000
• Blue Value 3500
• Blue Value 3000
• HSA Compatible HDHP PPO 1800 Ded 80 Coin
• HSA Compatible HDHP PPO 2600 Ded 100 Coin
• Blue Value 2000
• HSA Compatible HDHP PPO 1150 Ded 80
• HSA Compatible HDHP PPO 1800 Ded 100 Coin
• Right Plan
• HSA Compatible/HDHP PPO 1150 Ded 100 Coin
• Blue Value Select 1500
• Blue Value 1000
• Flex Plus 10000
• Blue Value Select 750
• Flex Plus 5000
• Blue Value Select 500
• Flex Plus 2500