UNIVERSITY SYSTEM OF GEORGIA INDEMNITY PLAN

1
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

2
PREVENTIVE CARE CHARGES
100 COVERAGE - NO DEDUCTIBLE 750 per person
per plan year

• IMMUNIZATIONS
• ROUTINE PHYSICAL EXAMINATIONS
• EYE/HEARING EXAMINATIONS

3
HOSPITAL CHARGES
90 COVERAGE AFTER DEDUCTIBLE

• Inpatient Surgery
• Outpatient Surgery
• Maternity Delivery
• Hospital Stay

4
NON-HOSPITAL CHARGES
80 COVERAGE AFTER DEDUCTIBLE

• AMBULANCE SERVICE
• OFFICE VISITS
• PREADMISSION TESTING

5
MEDCALL

• Emergency Room Referral
• Surgical Services 90 UCR paid when referred by
  MedCall.
• 80 without referral
• Non-Surgical 80 UCR
• 70 without referral

6
UnicareMedical Utilization Review

• HOME HEALTH CARE/HOSPICE CARE
• INPATIENT PSYCHIATRIC TREATMENT
• MATERNITY ADMISSIONS
• SUBSTANCE ABUSE TREATMENT
• SURGERY ADMISSIONS (inpatient outpatient)
• DIAGNOSTIC TESTS
• UNICARE, INCORPORATED 1-800-233-5765

7
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.)

8
VISION 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

9
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

10
UNIVERSITY SYSTEM OF GEORGIACOST PER MONTH

• -Employee- 140.62
• -Employee/Spouse 295.20
• -Employee/Child 253.00
• -Family 407.64