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AFLAC: PPO
Summary of Benefits and Coverage:
What this Plan Covers & What it Costs
Coverage Period:
01/01/2017 - 12/31/2017
Coverage for:
Individual + Family |
Plan Type:
PPO
Common
Medical Event
Services You May Need
Your Cost if
You Use an
In-Network
Provider
Your Cost if
You Use an
Out-of-Network
Provider
Limitations & Exceptions
If you have a test
Diagnostic test (X-ray, blood work)
No Charges
30%
Coinsurance
––––––––––––––––––––none––––––––––––––––––––
If you have a test
Imaging (CT/PET scans, MRIs)
$50
Copay/Visit
30%
Coinsurance
Copay applies to facility charges only. Precertification required.
If you need drugs
to treat your illness
or condition,
prescription drugs
are covered by CVS
Caremark.
More
information about
prescription drug
coverage is available
atwww.caremark.com
or call toll-free at
866-818-6911.
Tier 1 - Generic drugs
$10
Retail
$20
Not Covered
$100 individual deductible; maximum family deductible
$200. The deductible is waived for generic drugs and if
mail service or CVS/pharmacy is used for 90-day supplies.
If you request a brand name drug when a generic is
available you may pay the applicable brand copay plus
the cost difference between the brand and the generic.
Contraceptives are covered at 100% as outlined by health
care reform (Affordable Care Act). Standard flu shot
injection is covered at $15.
Tier 2 - Preferred brand drugs
$30
Retail
$60
Not Covered
Tier 3 - Nonpreferred brand
drugs
$70
Retail
$140
Not Covered
Tier 4 -
Specialty drugs
More information about specialty
drugs is available at
www.cvsspecialty.com
Same as retail/mail
Not Covered
$100 per participant deductible; maximum family
deductible $200. If you request a brand name drug when
a generic is available, you may pay the applicable brand
copay plus the cost difference between the brand and
the generic. CVS/specialty serves as the plan’s exclusive
provider of specialty drugs. Specialty drugs are limited
to one fill or one month’s supply per month however your
costs are based on the days’ supply.
If you have
outpatient surgery
Facility fee (e.g., ambulatory
surgery center)
20%
Coinsurance
30%
Coinsurance
Precertification may be required.
Physician/surgeon fees
20%
Coinsurance
30%
Coinsurance
––––––––––––––––––––none––––––––––––––––––––
If you need
immediate medical
attention
Emergency room services
$200
Copay/Visit
$200
Copay/Visit
If admitted, the ER copay is waived. Failure to obtain
pre-authorization may result in non-coverage or reduced
coverage by 50%.
Emergency medical transportation
20%
Coinsurance
20%
Coinsurance
––––––––––––––––––––none––––––––––––––––––––
Urgent care
$35
Copay/Visit
30%
Coinsurance
––––––––––––––––––––none––––––––––––––––––––
If you have a
hospital stay
Facility fee (e.g., hospital room)
20%
Coinsurance
30%
Coinsurance
Failure to obtain pre-authorization may result in
noncoverage or reduced coverage by 50%.
Questions:
Call 888-893-6366 or visit us at www.bcbsga.com. If you aren’t clear about any of the highlighted terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 888-893-6366 to request a copy.
Appendix and Legal Notices Summary of Benefits REFERENCE Salary Redirection Managing Your Retirement 401(k) Plan Short- and Long-Term Disability Accidental Death and Dismemberment Group Term Life Flexible Spending Employee Assistance Plan ADDITIONAL BENEF ITS Vision Plan Dental Plan Options Health Plan and Prescription Drug Benefits HEALTH AND WELLNESS PLANS How to Apply for Aflac Coverage How to Make Your 2017 Benefits Elections 2017 Benefits Highlights WELCOME About This Guide When to Enroll Glossary Quick Reference