Blue Cross Blue Shield of Georgia Right Plan Plan Information

Plan Name: Right Plan

Plan Type: PPO

Physician Choice: You choose specialist(s)

Calendar Year Deductible In-network: $0

Calendar Year Deductible Out-of-network: $0

Coinsurance In-network: Plan pays 60%

Coinsurance Out-of-network: Plan pays 60%

Calendar Year Coinsurance Maximum In-network: $7500

Calendar Year Coinsurance Maximum Out-of-network: $7500

Physician Office Visit In-network: $40 office visit copay

Physician Office Visit Out-of-network: Plan pays 60%

Preventive Care Adults In-network: $40 office visit copay

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

Preventive Care Children In-network: $40 office visit copay

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

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

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

Outpatient Care In-network: Plan pays 60%; $500 copay per surgery, facility charges

Outpatient Care Out-of-network: Plan pays 60%; $500 copay per surgery, facility charges

Maternity Physician In-network: Not covered

Maternity Physician Out-of-network: Not covered

Hospital Inpatient Services In-network: Plan pays 60%; $500 copay per admission

Hospital Inpatient Services Out-of-network: Plan pays 60%; $500 copay per admission

Physical/Occupational Therapy, Chiropractic In-network: Plan pays 60%, 30 visits per year combined specialties

Physical/Occupational Therapy, Chiropractic Out-of-network: Plan pays 60%, 30 visits per year combined specialties

Behavioral Health/Substance Abuse Hospital Inpatient: $100 per day; 30 day maximum; $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%

Emergency Room Non-Medical Emergency or Non-Serious Accidental Injury: Plan pays 60%

Prescription Drugs: Calendar Year Prescription Drug Deductible: $200; Generic Formulary: $15; Brand Formulary: $30; Non-Formulary: $45 Drug deductible does not apply for Generic drugs.

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
• HSA Compatible/HDHP PPO 1150 Ded 100 Coin
• Blue Value Select 1500
• Blue Value 1000
• Flex Plus 10000
• Blue Value Select 1000
• Blue Value Select 750
• Flex Plus 5000
• Blue Value Select 500
• Flex Plus 2500