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* For more information about limitations and exceptions, see
plan
or policy document at
https://eoc.bcbsga.com/eocdps/2X7YSMG01012018
.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)
health, or
substance abuse
services
Not Applicable
apply
Other Outpatient
20%
coinsurance
50%
coinsurance
--------none--------
Inpatient services
Not Applicable
20%
coinsurance
50%
coinsurance
--------none--------
If you are
pregnant
Office visits
Not Applicable
20%
coinsurance
50%
coinsurance
Maternity care may include tests
and services described elsewhere
in the SBC (i.e. ultrasound).
Childbirth/delivery professional
services
Not Applicable
20%
coinsurance
50%
coinsurance
Childbirth/delivery facility
services
Not Applicable
20%
coinsurance
50%
coinsurance
If you need help
recovering or
have other
special health
needs
Home health care
Not Applicable
$40/visit
deductible
does not
apply
50%
coinsurance
120 visits/benefit period.
Rehabilitation services
Not Applicable
$80/visit
deductible
does not
apply
50%
coinsurance
*See Therapy Services section
Habilitation services
Not Applicable
$80/visit
deductible
does not
apply
50%
coinsurance
Skilled nursing care
Not Applicable
20%
coinsurance
50%
coinsurance
60 days/benefit period for
Inpatient rehabilitation and skilled
nursing services combined.
Durable medical equipment
Not Applicable
50%
coinsurance
50%
coinsurance
*See
Durable Medical Equipment
Section
Hospice services
Not Applicable
20%
coinsurance
50%
coinsurance
--------none--------
If your child
needs dental or
eye care
Children’s eye exam
Not Applicable
No charge
Amount above $30
reimbursement/vis
it
deductible
does
not apply
*See Vision Services section
Children’s glasses
Not Applicable
No charge
Amount above $45
reimbursement/oc
currence
deductible
does not apply
Children’s dental check-up
Not Applicable
10%
coinsurance
10%
coinsurance
*See Dental Services section