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* For more information about limitations and exceptions, see
plan
or policy document at
https://eoc.bcbsga.com/eocdps/2X76SMG01012018
.provider
for some services (such as lab work). Check with your
provider
before you get
services.
Do you need a
referral
to see a
specialist
?
No.
You can see the
specialist
you choose without a
referral.
All
copayment and coinsurance costs shown in this chart are after your
deductible hasbeen met, if a
deductible applies.
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)
If you visit a
health care
provider’s
office
or clinic
Primary care visit to treat an
injury or illness
Not Applicable
$20/visit
deductible
does not
apply
40%
coinsurance
--------none--------
Specialist
visit
Not Applicable
$40/visit
deductible
does not
apply
40%
coinsurance
--------none--------
Preventive care
/
screening
/
immunization
Not Applicable
No charge
30%
coinsurance
Non-
Network
preventive care
services for children prior to their
6th birthday have no
deductible
.
You may have to pay for services
that aren't preventive. Ask your
provider
if the services needed are
preventive. Then check what your
plan
will pay for.
If you have a test
Diagnostic test
(x-ray, blood
work)
Not Applicable
20%
coinsurance
40%
coinsurance
--------none--------
Imaging (CT/PET scans, MRIs)
Not Applicable
20%
coinsurance
40%
coinsurance
--------none--------
If you need
drugs to treat
your illness or
condition
More information
about
prescription
drug coverage
is
available at
http://www.anthe m.com/pharmacyiTier 1a - Typically Lower Cost
Generic
$5/prescription
deductible
does not
apply (retail) and
$13/prescription
deductible
does not
apply (home
delivery)
$15/prescription
deductible
does not
apply (retail)
40%
coinsurance
deductible
does not
apply (retail and
home delivery)
*See Prescription Drug section
Tier 1b - Typically Generic
$20/prescription
deductible
does not
apply (retail) and
$50/prescription
$30/prescription
deductible
does not
apply (retail)
40%
coinsurance
deductible
does not
apply (retail and
home delivery)