|
GBA Insurance Trust, Inc. |
2008 Summary of Medical Benefits--Plan # 280
Click here for a printable version of
this summary |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Calendar Year Deductibles |
|
|
|
|
|
|
Individual (In-Network and Out-of-Network) |
$750 |
|
|
|
Family (In-Network and Out-of-Network) |
$2,250 |
|
|
|
|
|
|
|
|
|
|
|
Out of Pocket Expense Per Calendar Year |
|
|
|
|
|
|
Individual (Deductible Included) |
|
$3,250 |
|
|
|
Family (Deductible Included) |
|
$6,500 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Preferred |
Other |
|
|
|
|
|
|
|
|
|
|
|
Co-Insurance % Payable Unless Specified (After Deductible) |
80% |
60% |
|
|
|
|
|
|
|
|
|
|
|
Emergency Services (Life Threatening Med. Conditions) |
80% |
80% |
|
|
|
|
|
|
|
|
|
|
|
Inpatient Psychiatric Care ** |
|
|
80% |
60% |
|
|
|
|
|
|
|
|
|
|
|
Office Visits After Deductible |
|
|
80% |
60% |
|
|
|
|
|
|
|
|
|
|
|
Prescription Drug Program Co-Payment |
|
|
|
|
|
|
Generic/Brand Name Formulary/ Non-Formulary |
$15/$35/$60 |
60% |
|
|
|
|
|
|
|
|
|
|
|
Preventive Care |
|
|
|
$500 max |
Limited |
|
|
|
Ages 1-5 |
|
|
|
80%* |
60%* |
|
|
|
Ages 6-17 |
|
|
|
80%* |
60% |
|
|
|
Adult PAP Smear, PSA & corresponding facility charge |
80%* |
60% |
|
|
|
Adult routine physical by schedule |
|
80%* |
0% |
|
|
|
Mammogram |
|
|
100%* |
100%* |
|
|
|
|
|
|
|
|
|
|
|
Skeletal Adjustments ($500 Maximum Benefit) |
80% |
60% |
|
|
|
|
|
|
|
|
|
|
|
Important Numbers: |
|
|
|
|
|
|
|
Physician Network on the Internet |
|
www.bcbsga.com |
|
|
|
|
Paragon Customer Service |
|
|
877-380-0193 |
|
|
|
|
Claims on the Internet |
|
|
www.paragonbenefits.com |
|
|
|
|
Plan Certificates |
|
|
www.gabankers.com/gbait/plancertificatebooklets.htm |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
*Deductible waived |
|
|
**Complies with Mental Health Parity Act and has limited benefits. |
|
|
This is a summary and not a contract. Please refer to certificate
booklet for complete benefit details. |