Post on 24-Dec-2015
UNIVERSITY SYSTEM OF GEORGIA INDEMNITY PLAN
$2,000,000 Lifetime Maximum
DEDUCTIBLE
$300 PER PERSON
$900 MAXIMUM PER FAMILY
ANNUAL OUT-OF-POCKET LIMIT $2,000 PER PERSON
$4,000 MAXIMUM PER FAMILY
100% FOR REMAINDER OF CALENDAR YEAR WHEN SERVICES ARE IN BCBS NETWORK
PREVENTIVE CARE CHARGES
IMMUNIZATIONS
ROUTINE PHYSICAL EXAMINATIONS
EYE/HEARING EXAMINATIONS
100% COVERAGE - NO DEDUCTIBLE $750 per person per plan year
HOSPITAL CHARGES
• Inpatient Surgery
• Outpatient Surgery
• Maternity Delivery
• Hospital Stay
90% COVERAGE AFTER DEDUCTIBLE
NON-HOSPITAL CHARGES
AMBULANCE SERVICE
OFFICE VISITS
PREADMISSION TESTING
80% COVERAGE AFTER DEDUCTIBLE
MEDCALL
Emergency Room Referral Surgical Services 90% UCR paid when
referred by MedCall.80% without referralNon-Surgical 80% UCR70% without referral
HOME HEALTH CARE/HOSPICE CARE INPATIENT PSYCHIATRIC TREATMENT MATERNITY ADMISSIONS
SUBSTANCE ABUSE TREATMENT SURGERY ADMISSIONS (inpatient & outpatient) DIAGNOSTIC TESTS
UNICARE, INCORPORATED 1-800-233-5765UNICARE, INCORPORATED 1-800-233-5765
UnicareMedical Utilization Review
PHARMACY PROGRAM
Network of Retail Pharmacies
Services Outside of Network
90 Day Maximum Drug Supply
$10 co-payment for generic $25 co-payment for preferred brand name 20% of non-preferred brand name cost
($40 min. and $100 max.)
VISION CARE PROGRAMVISION CARE PROGRAM BLUE CHOICE VISION PROVIDERS LensCrafters Independent Optometrists Independent Ophthalmologists
VISION DISCOUNTS LensCrafters Preset Vision Packages ~Silver, Gold, and Blue Choices~ 30% Off Eyeglasses/Frames/Lenses/Lab Fees 25% Off Non-Prescription Sunglasses Low Fixed Prices on Contact Lenses
MEDICAL SERVICE
UNIVERSITY SYSTEM OF GEORGIA COVERAGE ANYWHERE IN THE WORLD
(Subject to Balance Billing effective 01/01/2003) HEALTH MAINTENANCE ORGANIZATIONS
ONLY ACUTE CARE AND LIFE THREATENING EMERGENCIES
COVERED OUTSIDE OF SERVICE AREA
UNIVERSITY SYSTEM OF GEORGIACOST PER MONTH
-Employee- $140.62
-Employee/Spouse $295.20
-Employee/Child $253.00
-Family $407.64