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* For more information about limitations and exceptions, see
plan
or policy document at
https://eoc.bcbsga.com/eocdps/2X76SMG01012018
.Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, &
Other Important Information
Preferred
Network Provider
(You will pay the
least)
In-Network
Provider
(You will pay
more)
Non-Network
Provider
(You will pay the
most)
nformation/Anthem Select
Drug List
deductible
does not
apply (home
delivery)
Tier 2 - Typically
Preferred
Brand & Non-Preferred
Generics
$40/prescription
deductible
does not
apply (retail) and
$120/prescription
deductible
does not
apply (home
delivery)
$50/prescription
deductible
does not
apply (retail)
40%
coinsurance
deductible
does not
apply (retail and
home delivery)
Tier 3 - Typically Non-
Preferred
Brand
$80/prescription
deductible
does not
apply (retail) and
$240/prescription
deductible
does not
apply (home
delivery)
$90/prescription
deductible
does not
apply (retail)
40%
coinsurance
deductible
does not
apply (retail and
home delivery)
Tier 4 - Typically
Specialty
(brand and generic)
25%
coinsurance
up to $300
deductible
does not
apply (retail and
home delivery)
35%
coinsurance
up to $300
deductible
does not
apply (retail)
40%
coinsurance
deductible
does not
apply (retail and
home delivery)
If you have
outpatient
surgery
Facility fee (e.g., ambulatory
surgery center)
Not Applicable
20%
coinsurance
40%
coinsurance
--------none--------
Physician/surgeon fees
Not Applicable
20%
coinsurance
40%
coinsurance
--------none--------
If you need
immediate
medical
attention
Emergency room care
Not Applicable
$250/visit
deductible
does not
apply then 20%
coinsurance
Covered as In-
Network
Copay waived if admitted.
Emergency medical
transportation
Not Applicable
20%
coinsurance
Covered as In-
Network
$50,000 maximum
benefit/occurrence for Non-
Network Providers
.
Urgent care
Not Applicable
$100/visit
deductible
does not
apply
40%
coinsurance
--------none--------
If you have a
Facility fee (e.g., hospital room)
Not Applicable
20%
coinsurance
40%
coinsurance
60 days/benefit period for