-~A ;goo.1;4 $/ A14 2004PlXJ5 STATE HEALTH BENEFIT PLAN JULY 1, 2004 - JUNE 30, 2005 o NEW EMPLOYEE HEALTH PLAN DECISION GUIDE o GEORGIA DEPARTMENT OF COMMUNITY HEALTH PHONE NUMBERS AND CONTACTS FOR BENEFIT AND PROVIDER INFORMATION PPO, PPO CUOICE OPTIONS (BASIC, PREMIER), INDEMNITY OPTIONS (BASIC, PREMIER) ~ For rate information, cont:tct your personnellpayroll representative ~ For benefit COVCr'dgC information, call Member Services at: (BOO) 483-6983 (outside Atlanta), or (404) 233-4479 (in Atlanta) TOO Line for the hearing impaired: (800) 269-4719 (outside Atlama), (404) 842-8073 (in Atlanta) You can get both National and Georgia PPO prO\ri.der information online at: www.healthygeorgia.com BEHAVIORAL HEALTH SERVICES All Options except HMOs Contact Magellan for prOVider and referral information. 24 hours per day, 7 days per week. (BOO) 631-9943 www.magellanhcalth.com TOO line for hearing impaired: (678) 319-3860 or (BOO) 201-8316 PRESCRIPTION DRUG PROGRAM INFORMATION All Options except HMOs Contact the Pharmacy Benefits Manager, Express Scripts, at (877) 650-9342 TOO line for the hearing impaired: (BOO) 842-5754 TIle Basic and Premier dnlg lists are online at www.dch.st;J.tc.ga.us HMOs BlueChoice HeaJlbcare Plan (BOO) 464-1367 Online provider information: www.hcbsga.com or QGNA HealthCare Georgia (800) 564-7642 Online provider information: www.cigna.com KaIser Permanente (404) 261-2590 (800) 6]]-18]] Omine provider information: www.kaiserpermaneIJte,org UnitedHealthcare of Georgia (866) 527-9599 Online prm'ider information: www.provider.uhc.com/gdch If you enroll for health insurance co\'en.ge under me Sute Hcalm Benefit Plan (SHBP), )'Ou should receive a Swnmary Plan DeSCription (SPD) from your Human Resourus Depanment.This SPD reflects Plan benefits as of April 1,2003. Eolch yC'J.r, any Plan changes are printed in an Upf/ater, which is your official nOlice of Plan changes. You may request a copy of the July 2003 and 2004 Updaters from your personnel office or you may print a copy from the OCH Web Site, www.dch.statc.ga.lIs.Please keep your Summary Plan Description (SPD) and Updaters for fut\ltC reference. If you arc disabled and need this information in an alternative format, call the TOO Relay Service at (800) 255-0056 (text telephone) or (800) 2550135 (voice) or write the SHBP at P.O. Box 38342, Atlanta. GA 30334. PHONE NUMBERS AND CONTACTS FOR BENEFIT AND PROVIDER INFORMATION THE STATE HEALTH BENEFIT PLAN GENERAL INFORMATION INSIDE FRONT COVER .. 2 .. 4 OVERVIEW OF PLAN OPTIONS 9 ~ INDEMNITY OPTIONS - BASIC AND PREMIER 9 ~ PPO AND PPO CHOICE OPTIONS - BASIC AND PREMIER 10-11 ~ HMO OPTIONS. . 12 ~ HMO CHOICE OPTIONS . 13 BENEFITS COMPARISON: PPO, PPO CHOICE, INDEMNITY AND HMO OPTIONS. PHARMACY BENEFIT OPTIONS SEIlVICE AREAS FOR YOUR HEALTH PLAN OPTIONS ........ ....... 14 26 ........ 30 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) ANNUAL NOTICE DEPARTMENT OF COMMUNITY HEALTH PIlIVACY NOTICE ................ 35 . 36 How OCH USES AND DISCLOSES HEALTHCAIlE INFOIlMATION 37 WOMEN'S HEALTH AND CANCER RIGHTS ACT 39 PENALTIES FOil: MISIlEPRESENTATlON 39 o THE STATE HEALTH BE EFIT PLAN (SHBP) The Georgia Department of Community Health, which administers the State Health Benefit Plan (SHBP), continuaUy seeks to offer high-quatiry, affordable health coverage. Keep in mind, however, that you are the manager of your healthcare needs, and in turn, must take the time (0 understand your Plan benefit choices in order (Q make the; beSt decisions for yOli and your family. You may wonder how much your heahhcare benefits will COSt this year. Monthly premiums continue to increase and benefits arc modified. This is true for State Health Iknefit Plan (SHBP) members as well as employees and retirees nationally. Why docs this happen and how C:1O we better manage hcailhcare Costs? Actually, )IOU IlIll)1 be pari oftbe ~OllltiQIl. Peopk who do not understand thrir health eO\'er age pay more,according (0 theArnerican Medical Association.To help you beuer understand your plan and save your healthcare dollars, we have prepared a few points for you to consider. let's start by ralkjng about how the SHBP works. It is a seif-ftmtlet[ piau, which means Ih:u all expenses arc paid by employee premiums and employer funds. Approximately 95% of the premium goes dirt:ctly to pay hc;tlthcare claims and 5% goes toward adminisu:ring the Plan. The g...a. phs below provide you with an idea of how the cost of your healthcarc is allocated between employees and employers. - $400 0 $350 v : $300 "z 0 $250 .-.~ 0 $200 > $150 0 " $100 ~ $50 .-0 $0 --- Monthl)' Employee Contribution Montbl)' Employer Contribution .e Monthl)' Total Cost -+- STATE HEALTH BF.:\f.F1T PLA:'Ii - PPO SI:"OGLE 5345.68 $303.45 $304.65 __ - - - - - . 52'Z3.04 5289.00 _ __ _ .........."'-- - - - - - -.- _.... $286.62 ~----------.... ----- 5255.27 $255.27 ............... $2 27. 9 " 'I 5243.90 . ...545.10 FISCAL YEAR 2000 ...$45.10 FISCAL YEAR 2001 ..$48.18 FISCAL YEAR 2002 $49....38 FISCAL YEAR 2003 ...$59,.06 FISCAL YEAR 2004 5505.06 -S535.00 .+ ... -----~-~- $373:34 .54032B ..$1'31.72 -$S61.-=7? . - - -.- - ~~6.~~- $641.58 5461.30 5414.65 _$414.65 ... SI47.10~ ... $150.78 ..$180.28 So wbat Call you do to belp manage your beaUbcare cos's and keep down 'be increase in premiums? UNDERSTAND YOUR OPTIONS Compare all your plan options, considering both the premium and out-of-pocket costs that you may incur. Web sites and phone numbers are listed on the inside front cover of the Decision Guide if you need more information. CONSIDER ENROLLING IN A HEALTHCARE SPENDING ACCOUNT (HCSA) A HCSA helps you save tax dollars, approximately 26-45%, depending on your tax situation. By electing to use a HCSA, you may set aside up to $5,040 aJUllIally to cover healthrdated treatment for yourself and your dependents. Eligible expenses include deductiblcs, co-paymems, over-the-counter items for medical purposes and costs for certain procedures not covered under your health plan. The benefit of this account is that you're able to pay for these out-of-pocket costs with taxfn:e dollars! Contact your HR represemative for more information. BECOME A MORE PROACTIVE CONSUMER Of HEAlTHCARE Most people do not realize how much their treatments, medicines and tests cost. The illustration below is one example of the savings from choosing a generic drug instead of a bmnd-name drug. Steps You Can Take Include: ~ Keep a list of all medications you take. ~ Shop in-network providers and pharmacies. End out what your drugstore charges for a drug, not just the co-payment. .. Use generic medicines whenever possible. .. Make sure all procedures are preccrtified, if required. .. Make sure you get the results of any test or procedure. .. Talk to your prOVider. For example, ask your doctor if tests are necessary or if there are other forms of treatment. ~ Understand what will happen if you need surgery. ~ Check your Explanation of Benefits (if provided under your plan oplion) and if something does not make sense or seems to cost too much, ask your provider about it. These and other steps you take will help manage healthcare expenses, reduce your out-of-pocket costs and those of the Plan. In addition, these steps will help in keeping premium costs down. As an informed consumer of healthcare, you can have an impact on what you have to pay for premiums and be part of the solution. If after reading this Guide you want more information before making a coverage decision, you can request a Summary Plan Description (SPD) booklet and Updaters from your personneVpayroll office. PRF.SCRIPTION BRAND NAME GENERIC SAVINGS - - . . . 'Mi;'IBER'- ~O-PAYME~T , $25 -" ~ii-~- .TO-TAL~~...t."-l8~.(COSTl~ . PRESCJ!..I~.T_IO!,,!_. COST \To I.!H~!lB $90 565 $10 542 532 toyou-Sl5 - to SHBP - $33 o GENERAL INFORMATION ELIGIBLE DEPENDENTS A dependent is defined as: ~ Your spouse, if you are legally married as defined by the state of Georgia; ~ Your never-married dependcnt dtildren who are: o Natural or 1cgalJy adopted children and under age 19; e Stepchildren under age 19 who live with you al least 180 days per year; o Olher children under age 19 if they live wilh you permanently and legall~' depend on you for financial supporl; Your natural children. legally adopred children or stl:pchilth'en who were covered under the SHBr before age 19 and who are physically or menrally disabled and dcpendelll all you f do nO( apply to the ollt-of-pocket maximum. ~ Compare lhe Basic and Premier Phamlaq- Options. .. You must call the I\!'edical Cenific:nion Progr:ml 0'lCP) to prtcenify inp:uient stays at non-participating hospitals, and members must prcc:..:ertify certain outpatienl tests and procedures. Financial penalties apply if precerlific:uion rules are nOI followed. There arc two pharmacy options under the Indemnity Plan Options.-111ese options :Ire the IJldcmnit)' "asic and [ndemnity Premier. The medical benefits are the same under the Basic and Premier options. For additional informalion refer to page 26 of this Guide. NOt(: Somt contract groups thtU participau ill tilt SHE? au not tligib/~ to partieipau /11 tht IndrmnilJ Optioll. NOtE: The State Health Benefit Plan does not have the legal authority to intervene when non-participating providers balance bill; therefore, the State Health Benefit Plan cannot ..educe 0 .. elltninate amounts balance billed. In addition, the Health Plan cannot make additional payments above the allowed amounts when you are balance billed by non-participating providers. o PPO AND PPO CHOICE OPTIONS BASIC AND PREMIER The PPO Options offer you a network of over 14,000 Georgia participating physicians and 166 Georgia hospitals managed by 1st l\'ledical Network in the Georgia service area. You also have the added benefit of access to a national network of panicipating providers and hospitals across Ihe United States, which is managed by the Beech Stccet Corporation.The PPO Options offer you the choice and flexibility of using in-network or out-of-network providers. In order to receive the highest level of benefit coverage and avoid filing claims and balance billing, yOll will need to use an in-network provider. If YOli choose to use an om-of-network providc:r, the reimbursement will be at a lower level of benefit coverage. NOfe:The Transplant and Bch:lvioral Health Services (B1'IS) networks arc separate from the Ist Medical Network and the Ueech Street Network. '10 view the list of 1'1'0 providers onhne, visit www,hcalth)'georgi'l COlD. If you do not have Internet :lccess, call Member Services for provider information. .It is ultimatcly your responsibility to verify if a provider participates in the PPO network prior to receiving services. Providers may entcr or leave thc network at any time. There arc two pharmacy options under the PPO and PPO Choice Options - PP{) B::lsic and PPO Premier. TIle medical benefits arc the same under the PPO :ll1d PPO Choice Options. Please refer to page 26 for additional information . Points to Consider .. You do not need [Q select a primary GIn: physician (I'CP) or obtain referrals to see specialists. .. No balance billing when using participating PPO providers. .. You pay a minimal co-payment for in-network PPO physician visits. Other covered services are subject to dc::ducribles and co-insurance. .. YOli may access any licensed out--of-network physician, specialist or hospital at any time. However. you will genernUy pay more for out-of-nerwork services and dlarges are subject to b:llance billing. .. You must <..,111 the Medical Certification IJrogram (MCP) to precertify inpaticm stays and specified olllpatient procedufCs when you arc using olll-of-network providers or Beech Street providers (National PPO network). .. Some physicians affiliated with our PPO networks may not accept new patients at certain times during the year or may drop out during the year. Please check with the physician of your choice before you enroll in one of the PPO Options. .. Compare the pharmacy programs . .. In-nctwork hospitals may contract with ollt-of nctwork physicians or labs. You may be subject to balance billing by these providers. .. YOll have access to a mltional network of Beech Street providers. Your level of benefit coverage is gener-lIly different and you are subject LO Separate deductiblcs and out--of-pockct maximums. .. Physicians or hospitals leaving the network are not considered a qualifying event and do not allow you to dl,lIlge coverage. The C('Orgia Sf!rt'lce tln'ti i"di/tI('S the slate of Georgia ClIlti the border comll1lll/ilit'S of tbe Clxl1tcmoogtl, Telllu!SS(.'t' an'CI, illClut/iIl,C: 8rt/(l/e)1 C(lIIII~"; and pwnL, Cit); Alabama. TlJe zip axle area III which yOi/ receille a senl;ee is IISl'tI to tletermille Il'IJf!tber or nol JUll are ;1/ tbe Georgia serillee area.!iee j}(lge 30 for fllrtbe-r b/fonlultiQ1J. ADDITIONAL INFORMATION ABOUT PPO CHOICE - 8ASIC AND PREMIER lknefits under the PPO Choice Options arc the same in the PPO Et'lsic lmd PPO Premier Options. However, PPO Choice Option premiums arc higher. In return for a higher premium, rou can request that an out-of-network Georgia provider be reimbursed as an in-network provider. TIlis request is kno\vn as a Mnomination.... lf the out-of-network provider accepts your nomination, agrees to the PPO kes, and is approved by the PPO, you will receive in-network benefits for that provider. The in-network relationship between you and the provider remains in effect until you or the provider terminales Ihe llgreemenl. You may nominate as many eligible providers as you wish al lmy time during the Plan year. Points to Consider ... TIle PPO muSI approve YOllr provider nomination before you receive sen'ices_ ... If your provider docs not accept rour nomination, docs nOt accept the network fees, or is not approved by the PPO Network Administrator, then services from that provider are coyen:d at the lower, out-of-network benefit le\'el. SHBP rules do not aUow a member to change options when a nominated provider or the PPO rejects a nomination. ... Only proViders loc:ned and licensed in Georgia can be nominated, even if you live oul of state. After the PPO receives your nomination, the PPO has three business days to either reject or approve the nomination. For further details reWlrding the nomination process and to ohl'ain the necessary paperwork, please cantllel Member Services. Note:Tbe lJebavloral Healtb Services (BHS) amI transpltml proVider nelworks (/I'e separate from tbe PPO provider /letwo/'k in all PPO alld PPO Cboice 0pliollS. To nominate a JJHS provider, contact the HHS Pro,r;ram at (800) 63/-9943. I'o/, /'IO/lli!Ulliolis of transplant providers, C(/ll (800) 828-6518 (ullt~'ide Allanla). HMO OPTIONS HMO Options are available only [0 SHHP-eligibk t:mployces who livt: or work in an approved HMO service area in Georgia. -(See footnote.) Ple:ISC review the approved HMO service area list on pages 31- 34 of this Guide 10 determine if rou are eligible for an HMO. If your residence circumstanccs change during the Plan rear and yOli no longer live or work in an ::lpproved HMO service area, you will be required to changt: to another Plan option. HMOs provide prepaid benefits for most healthcare needs, with no bills or claim torms.Yol\ are responsible for selecting a primary care physician (PCP) from a list of participating providers. M(See footnote.) YOLI must n:ccive care from your PCP or from a physiLian or f.ICi!it}' referred by rour pcp for your expenses to tx: co\'ered. except in C"'dSCS of emergenc), and in other limilt:d cases. If you receive care from a physician other than your PCI~ or without your PCP rcferral, there is no covcrage even if the physician or f.lcility is in the HMO nct work. Points to Consider .. You must ;u.:ccss physicians, specialists and hOSpitalS offered through the HMO's network to receive henefits, except for emergencies as defined b}' the HMO. .. You choose a pcp to serve as your first point of conmct for most he;l1th<.:are seniccs. "(See footnotc.) Your covered family members mUSt also select a pcp. TIle PCP is responsible for coordinating rour healthc:ue services (speci:llislS, ancillary providers, hospitals). ,. Providers may drop Out of the network al any time during lhe year and this is 11m a qualifying event to change coverage. .. See the Pharmacy lkndlt Options on page 26 to compare the pharmacy programs. .. YOLI pay only a minimal co-paymem for liMO innetwork ph~'Sician visits. prescriptiOn drugs and somc other covered services. .. You pay the full cost for non-referred sen'ices and for services received out.<;ide tht: H)tOs panicip:uing netWork, except for t:IJlergencies as defined by the HMO. .. YOli ha\'e coordinatc...-d care through a network of HMO participating pro\'iders. ,. In most cases, HMOs do nOl have: a deductible to meet, so your outol~pocketcost may he lower. .. There are no pre-cxisting condition limitations. .. You may be required to follow the HMO's standardized treatmcnt plan for your condition. For example, you mar be required to recei\T treatment frOI11 your primaq' care physician for a specified period befort: being referred to a specialist. .. All services received outside the State of Gcorgia must be: coordinated through the HMO. C-) Some contract groups that participate in the SHBP are not eligible to participate in the HMO Options. C--) Note: UnitedHealthcare HMO does not require you to select a pcp or obtain referrals to see specialists. HMO CHOICE OPTIONS If yOlL are eligible for an HMO Option, YOll also :m: eligible for th:u HMO's Choice Option. 11110 Choice Option benefits are the samc as the 11.::tjX'cti\e regular HMO Option bendirs. HOWe\TC the Choice Option premiums are higher. In return for a higher premium, the HMO Choice Option gin:s llll"mbers the opportunity to reque:tl an OUI-of-nenvork Georgia provider to be trc;ttcd as an in-network provider. This requesl is known as a "nomination.~ You may nominatc providers if Ihey arc located ant! licensed in Georgia and offer services covt:l1::d by the HMO. In ;Iddition, you may nominate.: as many eligible providers as YOLI wish at any time during the Plan YC:lr. PoinlS 10 Consider ~ 111e HMO !TIllSt approve your OLlt-of-nctwork provider before YOli receive medical scn'ices. ~ If the ollt-of-lletwork provider accepts YOllr nomination. accc.:pls the 1-I.\IOs fees and is appro\"t:d by the H.\10, you may receive in-llt:twork bcnefits from that proVider. ~ If your prm'ider does not aCCt:pt your nomination. docs not accept the.: HMO's fees, or is not approved by till' HMO, sen'ices from that providt:r are not covered. ~ Ikferral rules apply when the nominated doctor is a specialist for the B1ueChoice, elGNA and Kaiser HMOs. ~ SHllP rules do nOI pcrm..it a member to change options \.."hen a nominatcd provider or HMO rejects a nomination. Plcase contact thc Mcmber Services Departmcnt of the respectivc HMO directly to find out more ::lbout the rcquired procedures and paperwork necessary to nominate a provider. Telephone numbers are listed on Ihe inside front cover, You ARE PART OF THE SOLUTION! .~U'N'DERSTA~DING Yo.u~' HEALTH TlJis secti011 complres specific bellefllS witlJill IlJe PPO, Il1dertmily alld HMO OpUOIIS. FOI' more speciJlc itifm'matioll Oil covered services, call the Member Services IllImbers listed Oil the illside from cover, 00 o o BENEFITS COMPARISON: PPO, INDEMNITY AND HMO OPTIONS SCIIIWULE 01' B.:NEFITS FOR You AND YOUR DEPENDENTS - JULY 1, 2004 Ma.'timum Lifetime Benefit (combined for all SHBP Options) Pre-Existing Conditions (l51 year in Plan only, subject 10 HlPAA) Lifetime Benefit Liotit for Treatment of: (combined for PPQ Option and Indemnity) .. Temporomandibular joint dysfunction (fMJ) .. Substance abuse .. Organ and tissue tr:msplants ... Home hypcr:llimcnt:ttion DeductibleslCo-Payments: ... Deductible-individual to Deduclible-f.lmily m:lximum .. Hospital deductiblc/admissionexcluding B1"IS and trJ.llsplants ... Hospital deductible/admissionBHS and transplants .. Hospital co-payment Annual Out-of-Pocket Limits: .. Individual (you or one of your dcpendents) .. Family (you and yOllr dependents) .. BHS program (per patient); BHS authorized care only 5400 $1,200 $250 $100 Nonc S 1, 0 0 0 SV)(}() 52 million 51,000 51,100 3 episodes 5500,000 $;00,000 lo-Nctwork/OUI-of-SI:1te & OUI-QfNctwork amounts <.'()mbint:d $500 51,500 5250 5250 S100 $100 None None Ln-NetwOl'k/Ollt-of..State & Oul-of..Network amounts combined 52,000 52,500 S4,OOO Primary Care Physician and/or Referral Required Primary Care Physician or Specialist Office or Clinic Visits: .. Treafment of illness or injury No No 100% NR- :lfrt:r a per visit co-payment of $30; not subject [0 dcductible 100% NR- after :I per \'isit co-payment of 530: not subject to deductible No 60% of DONn-; subject to deductible - See legend on page 24 for definitions of NR, OONR and IR. $2 mmion $1,000 BWF.CtJOICf Tbe Plan Pays $2 million None HMO OPTIOSS OGNA KAl."ER PERMANEI'I,'TE The Plan Pays: $2 million None The Plan Pays. No lifetime benefit maximums None UNITEOHEALnlC.o\RE The P/(m Pays. 52 million None $1,100 3 episodes $,00.000 S,OO,OOO '400 $1.200 '400 Sloo None S2,O COVERED SERVICES ----'-'-"'- - - >...... Primary Care Physician or Specialist Office or Clinic Visits for the Following: .. Wellness care/prcvt:ntivc hcalthcarc .. Well-newborn exam .. Well-child exam$ and immunizations .. Annual physicals .. Annual gynecological exams 100% of NR aCler 100% of NK after $.30 co-payment per office SjO co-paymelll per offiCI: visit.IOO%ofNI~ with \'isit. 100% of NK with no co-payment for a$sodatctl no co-payment for associated tests and immunLwtions. tests and immunizations. Maximum of S500 payable ~bximurn of $500 payable per person per Plan year pef persoll I)(:r Plan year for aU prcn:nth'e services. fOf all preventive services. M:lximulTI combined with M:tximlllll combined with In-Network/Oul-Qf-5tate benefit. IJl.-Nt.""twork/Gcorgia benefit. Not cove~d" Charges do not :lpply to deductible or annual out-ol:pocket limits. NOltS: Lab and ICSI charges include such services as m:unmograms. proSI':l.IC scrcenings/PSAs, and pap tesrs. Gwered according to prc"cnrh"e ,--a~ age schedules. Con:red care schedliles are online al www.hcJ.hh\geol\:ill.com or call ,\Iember SCrvief.-'S at (ROO) 483-6983 (olllside Allama) or (404) 2334479 (insillc: Allama). Maternity Care (prenatal, delivery and postpartum) 90% of Nil; not subject 10 deductible after initial 530 co-payment sow' of NR; not subject 10 deductible after initial 530 co-payment 60% ofOONR; subject to deduetihle and to balance billing Physician Services Furnished in a Hospital .. Surgery in general, including charges by :surgeon, anesthesiologist, pathologist and radiologist 90% of NIt; SUbject to deduCliblc sow, of NR: subjeci to dl--"ductible 60% of 001\l1t; subject to deductible .. Lnpaticnt well-newbonl exams 100% of NR: not subject to dcductible 100% of NR; llot subjeCl 10 deductible Not covered Physician Services for Emergency Care 90% of NR: subject 10 deductible 90% (If NR: subject to In-Network/Georgia tleductible 9O'Xo of NR: subjeci to In-Network/Geargia deductible and la balance billing Outpatient Surgery .. When billed as office visit 90% of NR: SUbjCLt to deductible 80% of NR: subject to uedllctible 60% arOONI{: subject 10 deductible .. When billed as outpatient surgery at a facility IIOSPtTAL SER\ ICF.S Inpatient Services .. Inpmienr care. delivery and inp:tticnr short-tt:rrn acutc rehabilitation services .. Outpatient scrvicc$ .. Nan-emergency USe of Ibe emergency room .. Other 90% of NK: subject to (Jeduclible 90% of 1\'R: subject ta a per :ldmis."ion detluctible of 5250 90% of Nit; subject to deductible; subject 10 S 100/Visit co-payment 80'}6 of Nit: subject to deductible 8Q%ofNIt: subject to a per admission deductible of 5250 8(jJ(, of NR; sLlbjcl.:t to deullctible; subject to SIOO/visit l.:o-paymem 6O'J(, of OONR: subject 10 ueductible 6O%0fOONR; ~ubjeci to a per admission dcductible of $250 (i)'X, of OO~lt sllhject to deductible; sllbjecr 10 $1 OONis!! co-p:trlllent .. WeU-newbom care 100% of ;'\TR: not subjcci to deductible I()()'h, of :\'K: not sllbjeL"t 10 deductible Not cO\'ercd INDf.:\tNITY OPTIONS BAStC A."lD PRF.toIIER - Tile e../~'!. ~aJ's.~..(;.~ 9O'J' of lR per office visit after deductible. 1~ of IR with no deductible for associated lab and test charges, up to a maximum of 5200 per person per 1'1:In year; additi01l:11 $125 benefit for screening mammogram. BLUECIIOICE HMO OPTIo:\,s CIGNA UNITEDHEAL111CARE 17Je Plait Pa)'s' TlJe Pfti,~ P!i)'S.' n.Jp PI,,;' p(l)'~j.Jfi ~ n.Je Plan Pays 100% after a per visil co-payment of S15 for primary GIre amI 520 for specialty care. No co-pa}'ment for immunizations and mammograms. 100% after a per \'Isit co-payment of S 15 for primary care and 520 for specialty care. No co-payment for inulluniz.,1lions and mammograms. 100% aft~r a per visit co-paymenl of 5 I; for primary care and 520 for specialty care. No co-parme.-"1lt for immul1i7~1.tions and m:m1mogrnIllS. 100% after a per \'isil co-parment of 5 I; for primary care and 520 for specialty care. No l.'O-parment for inmlUl1i7.ations and m:unmogrJ.IllS. Note: PPO nOles to the lett also apply hen:. 90% of lit; subjeci 10 dcductible 100% after initial 520 co-payment 100% after inilial 520 co-payment 100% after initial 20 co-payment 100% after initial $20 co-payment 90'.\ of IR: subject to dctluctihle 100% 100% 100% 100'; Not cO\Trcd 100% 100% 100% 100% 90% oflR:subrcct to deductible anu to b:llance billing from lloll1,anicipating providers 100% after applicable 100% after applicable 100% after applicable 100% after applicable eo-pa}'l1lcnt co-payment co-payment co-paym~nt 90% of In: subjecl lO dnluLtibk 90'X, of Ill; subject to dcductible 100% after $20 co-payment if billed as office visit $100 co-payment for outpatient surgery 100% after $20 eOpayment if billed as office visit $ I 00 co-payment for outpatient surgery 100% aftcr $20 co-payment if billed as ofJke visit $ 100 co-payment for outpatient surgery 100% aftcr $20 co-payment if billed as office visit S100 copaymcllt for outpatient surgery 90% ofIR; subjecl 10 :t l>er admission dcducliblt: of 5400 90% of II{; subje.--x.1 lO deductible. If SCf\;ces are in conjunction with non-emcrgency lise of the emergency room, benefit also subject to $IOO/\'isit co-payment 90% of lit: subject to ptT admission deduCtible of $1 00 100% after 100% after 5200 per confmement 5200 per confinement co-payment co-payment 100% after 100% after 200 per confinemem 5200 per confinemelll co-payment co-paymenl PCP prior PCP prior pcp prior authoriZ3lion required allthori7..arion reqUired authori7.ation required for coverage for covcrnge for eo\'cr:lge Requires prior authori7.at'ion from 1'1"10 100% 100% 100% a ( Cb",., """""",'<11'1;.1101 100% Outpatient Surgery .. Hospital/Facilit}' Emergenf.1' Care ... Treatment of :In emergency medicaJ condition or injury 90% of NR; subject to deductihle 80% of NR; suhject to dcduclible 60% ofOONR; subject to deductible 90W. NI{ after a per \'isit co-payment of $100; co-insurance and hospital deductible appl}'. if admitted 9()'.l(, NR after a rx:r \'isit co-payment of $100; co-insurance and hospital deductible apply, if admitted 90% OONR after a per visit co-payment of S 100; co-insurance :md hospital deductible apply. if admitted. Subject to balance billing. Note: S 100 co-payments arc reduced ro $SO if referred by NurscCall 24 before receiving emtrgency roOm services. The ER co-payment is waived, if admitted within 24 hours. OUTPi\TlE:'lIT TF.STING. tAn, ETC. L1boratory; X-Rays; Diagnostic Tests; Injections, including Medications Covered Under Medical Benefits - for the Treatment of an Illness or Injury 90% of NR; subjcct to deductible SO%of NR; subject to deductible Allergy Shots and Serum I(X)"Al of NR; not subjf.'Ct to the 100.16 of NR; not subject to the deductible. If physician is seen. deductible. If physician is seen. visit is treated as an orfice visit visit is treateJ as :Ul offic~ visit subject to the per visit subtect to the per visit copayment of S30 copaymem of S30 AUergy Testing 90% ofNR: subject to deductible 80% ofNR; subject to deductible 60%ofOONR; subject to deductible 60% ofOONR; subject to deductible 60% ofOONR; subject to deductible BEHA\IORAL HEALTH Mental Health and Substance Abuse Inpatient Facility 90% of Nit; sllbjecl to deductible and separate hospital deductible, if admitted when authorized by 13115 90% of NIt; subjecl to deJlIetible and separate hospital deductible, if admitted when authorized by 13115 60% of NR; subject to deductible and separate hospilal deductible, if admitted when authorized br nHS Note: 1oA11 services require prior :lllthori7.:nion. 2. Inpatient facility charges (limited to 60 combined mental health and substance abuse days per person per Plan year). 5. Subst:lOceAbuse eO\'erage limite<.lto three episodes per lifetime. Partial Day Hospitalization and Intensive Outpatient 9O'Xi of NI{; 90'% of NI{; subject to deductible and subject to deduclible and separate hospital deductible, separate hospital deductible. if admined when if admitted when au(horizcd b~' BUS authorized b~' B1-IS No benefit Note: I. Ma.ximum Ix:nefit of 30 combined PHP/IOP \'isits/days pl'r person per P!:In rear. 2.l3encfit co\'cragc is only available when using an in-network i\bgelbt1 provider for partial/day hospitalization :tnJ intensive olltp:llient charges. INDEMNITY OPTIONS BASIC AND PREl'tUER The Plan Pays_ 90% of IR; subject 10 deductible 100% after $100 per 100% after $100 per 100% after $100 per 100% after S 100 per confinement co-paymelU confinement co-payment confinement co-payment eonlinemelll co-p:lymclll 90% U{ after a per visit co-payment of 5 100; co-insurance an<.l hospital deductible, if admitlcd, apply_ Subject to balance billing from non-participating providers. Note: PPO note 10 the left also applies here. 100% after a per visit co-payment of SSO (co-payment waived ifadmined) 100% aftcr a per visit co-paymcnt of $SO (co-payment waived if admitted) 100% after a per visit co-payment of SSO (co-payment waived if admiued) 100% after a peT visit co-payment of 550 (co-pa)'lllem waived if admitted) 90% of IR; subjecl to deductiblc 100% 100% 100% 100% 90% of IR; subject to deductible 90% ofIR; subject to deductible 100% for shots and serum after a $20 co-payment per visit 100% for shots and serum aftcr a $20 co-payment per visit $; for shots and 5;0 for :l six-month supply of serum 100% for shots and scnllTI after a 520 co-payment per visit 100% after a 520 per 100% after a 520 per 100% after a 520 per 100% after a 520 per visit co-payment visit co-payment visit co-payment visit co-payment 90% of II{; subject to deductible if admitted when authorized by BHS Note: PPO notes to tile left also apply heTe. 90% of IR; subject to deductible and separat<.' hospital deductiblc, if admitted 100% after 5S0 co-payment per confinemcnt; limited to 30 days pC:f PI;m year 100% after S50 co-payment per confinement; limited to 30 days pte Plan year 100% after 5;0 cO-pa)'lllent per confinement; unlimited days for 1llent.al health; 3()-<.lay limit for subst:ll1ce abuse 100% after 5;0 co-payment peT confinement; limited to 30 days per Plan ycar Outpatient Care: Outpatient Care: Outpatient Care: Outpatient Care: 100% after S20 per visit 100% after 520 per visit 100% after $20 pef visit 100% after $20 per visit co-paymel1l; limited to co-payment; limited to co-payment; unlimited co-payment; limited to 2S visits peT Plan )'car 25 visits per Plan year days for mental health; 25 visits peT Plan year limited to 25 viSits for substance abuse pCT Plan )'car S50 co-p:l)'mellt per confinement; contact HI\'IO for specifics $50 co-payment per confinement; contact HI\'IO for specifics $50 co-paymcnt per confinemcnt.: contaCt HMO for specifics S50 Co-pa)'IllCllI per confincmem; contact HMO for specifics Note: PPO notes to the left also apply hCTe. 23 Hour Observation Room (requires prior authorization to receive coverage.) 90% of Nit; 90",.{, of NR; subject to $100 deductible subjl:l't to $100 dcductiblt' No benefit Professional Charges Inpatient (combined total for substance abuse lind mental health) 80% (If NR: subject to deductible. MaxilUUJll 1 visit per alithoriz-.:lIliay when :I\uhorized by 11II5. RO% of Nit subj-.:ct to ;0% of NR; subject to (ledw.:tible.l\Jlaximlim I visil deduclible and balance billing. pCI' :llItllorizcd day when Maximulll of 25 professional :ltlthorizcd by B1-IS. visits per person p<:r Plan year. Outpatient (Precertification required to receive coverage,) 80% of NH: subject to tkductiblc when authorized by BIIS, limited to 50 visits per Plan year. 80% of Nn; subject 10 50% of NR: subject to dedllc('ibk when aUlhoriZt.:d deductible (without authori- by 13I-1S, limited \(l 50 visits zation) and balancc billin~. per Plan )'c:lr. Maximum 25 combincd mcntal he:llth, substance abuse and brief therapy visits per person per Plan rear. Limited 10 scrvices rendered by a Psychiatrist (M.D.) or a Psychologist (ph.D.) Nou:: In-network maximum covcrage of 50-<:ombined mental hcalth, SUbSI:lllcc.: ahuse, :llld brief Iher-Ipy visits per pl:rsun per Plan ~car. Limil indudc.:s 25 out-of-nl~twork cUlUlsding sessions amJ 3 brief visils. Brief-Visit Therapy (limit - 3 visits per Plan year; requires BHS prior authorization.) 100%; not subjeci to deductibk 90%: not subject to dc.:dllctible No benefit Note: Visits are includcd in Ihe 50-visit limit of outpatiCIH care. DEN1'AL I v . ;- ' ,l i.-,.........,l.~ . _ ),>. -:-,-T-2-: .. ~ '''''1 Dental and Oral Care Coverage for mOSt procedures for the prompt rcp:Lir of sound naturaJ teeth or tissue for the cOn'eclion of damage caused by trnumatic injury 90% of NR; subjeCl to deductible and, if admitted, to hospilal deductible. Nctwork proViders may nOI be :lv;lilablc till' all covE-re(1 services: charges are paid at 90% NIt subject to balance billing 80% of NIt; subject to dcuuctible :1l1d, if admitted, to hospital deductible, Network pl'()vidt:rs may nOI be available for all covered services: charges are paid at 80% NIt suhject to b:llance billing 6o'J{, of OONn; subject to deductible and, if admitted. to hospital deductiblc Coverage of specific osseous surgeries for the treatment of pcricxlorltal disease Not covcrcd Not <:overed Not covered Temporomandibular joint syndrome (TMJ) 90% of NIt; subject to dcductible 80% of Nit subject 10 dedUCtible 60% of OONlt suhject to deductible Note: Coverage for diagnostic testing and nonsurgicallreatmcm ofT:\'1J, up 10 S1,100 pcr person lifetime maximum bcncfit.This docs not apply 10 the HMOs. INDEMNITY OPTIONS BASIC At~D PREMIER 90'X, of IR: subject to $100 deductible HO% of IR; subjt:ct to deduccih1e ant..! balance billing. PPO benefits apply when authorized by BHS. SO'X, of He subject to dedllcribJc when authorized br lUIS, limited to 50 visils per Plan year. 100% after $50 co-payment [00% 100% after $20 co-payment 100% after $50 co-payment 100% I(Xl% after S20 co-payment 100% after $50 co-payment 100% 100% after $20 co-payment 100% after $50 co-payment 100% 100% after $20 co-payment Narc: !'PO notcs 10 the left also apply here. [00%: not subject to deductible Note: PPO note to the left also applies here. Contact HMO for specifics Contact HMO for specifics Contact HI\Jl0 for specifics Contact HMO for specifics 90% of lH; subject to deductible and, if admillcd, to hospital deductible. 100% after applicable oral surgery co-payment and dental services for accidental injury to sound teeth 100% after Services/appliances 100% after applicable oral surgery for accidental injury to applicable oral surgery co-payment and llental sound and natural teeth: cn-payment and dental services for accidental 50% coverage services for accidental injury to sound teeth on first SI ,000, injury to sound tet:th 100% thereafter Not covered 90% of [H; subject to deductible Not covered Not covered Not covered Not covered 100% after applicable co-payment fnr related surgery and diagnostic services. Excludes appliances and orthodontic treatment. 100% after applicable co-payment for related surgery and diagnostic services. Excludes appliances and orthodontic treatment. 50% for non-surgical treatment: 100% after applicahle co-payment for related surgery and diagnostic services. Excludes appliances and orthodontic treatment. IOO'){, ;Iner applicable co-payment [or related surgery and diagnostic services. Excludes appliances and orthodontic tre(:hoice Vision Progr...m:1I (800) 377-6436 or visit u'ww.hchsg;u:om for lTlore infonnatioll. Vision prngr:lm avail:lbilir), is subject [0 change during the Plan rear. OTHER COVERAGE Ambulance Services for Emergency Care Notc:-L:J.nd or air ambulancc~to nearest fadlily to treat the condition. 9O%ofNR: subject to deductible 90% of NR; subject [0 In-NetWork/Georgia deductible 90% of OONR; subject to In-Network/Georgia deductible Note: limited [0 transportation for emergencies and benefits subject to balance billing for non-participating providers of ambulance scn'ices. Urgent Care Services in an Approved Urgent c."lre Center 90% of l'\R after :1 per visil co-payment of $45: subject to deductible 90% of i\R al'lt:r a per \'isit co,p:lyment of 4;; subject In deductible l'\ot applicable Home Healthcarc Services Approved in Advance by the MCP 90% of 1\'R subject In deductible 80''' of NR; subject to deductible 6O%0fOONR: subject to deductible -...... --- --- --- --- .-- ......... ............................... ...........-.._--- .._......_... NOles: I lome nursing cart': not rev1c:wed by the i'l'ICP C-Ovcrs two hours of medically necesS:lry skilled home care per day by RN or LPN if ordered by a physician: $7500 per Plan ye:lr limit is a combined total in Pro Options. Members share of cOSt is not applied to Plan year out-of-pocket limits. Skilled Nursing FacWty Services l\ot covered Not covt:red Not covered Hospice Care Note: Indemnity - Mer m:!y approve additional benefits in lieLl of Acute Care hospitalization. Durable Medical Equipment COME) - Rental or Purchase Outpatient Acute ShortTerm Rehabilitation Services 100% of Nit; suhject to deductible 100% of Nit; slIbjcct to deductible 60% ofOONR: sllbjecr 10 deductible 9O'Yn of NI{; subjcci 10 dcductible 80% of NR; subject to deductible I 60% of OONR; subject to {kductib1e 90% of NR: 80% of NR; 60% of OO:"lR; subject to deductible and subject to dedllL1ihle and subject [Q deductible 520 pcr visit co-paymenl 520 per vi!'>it co-p:tymem . ... . ... ... ... ... .. . ... ... ... .. + +. --- --_. _.- _ + Note: Coyemge for up to 40 visits per Plan fC'oIr whell conditions are met for phrskal.spccch, occllp.1tionalthcr:ll)ics and for Clrdiac rehabilitation. INDE.'\.I:'OL HMO Onlg List 510 S-'-, S40 Does not apply S-'-, 540 J::k>es not apply 5-'-, -2()'\, of l:ost: S450 per member, minimum 540. S 1.300 family maximum 5100 S,--, -200(, of cost: 5i50 per membt-r. minimum 540. 5 LjOO r.1mily maximum S100 S,--, 540 Does 110t apply Kaiser Drug Ust , Kaiser: Eckerd r.1.cility: Drugs 510 : 516 Kail>Cr f:lcility 525 Eckert! Dntgs Sjl Does not apply Does not apply -Note: Tbe NOli-Preferred n,.,md Cu-PaJ'",eut does 110/ apply 10 IlJe QI/l".,erfy MaximulIl OUI-of-Pocket. Please COIl fact C?acb HMO regarding pharmacy lists - BlueCboice (800) 464-1367: ClGNA (ROO) 564-7642; KlIisel' Pemulllellle (800) 6/ /-/8/ I; Ullitedl/eallbcare (866) 527-9599 BASIC AND PREMIER PREFERRED DRUG LISTS ~ Tht: pharmacy drug lists ;lre created, reviewed and COl1\illually updated by a team of healthc;\re professionals including physicians and pharmacists. ~ A medication becomes a prdnrcd drug based first on dficaq', then safcty and last on cost-tlfectivcncss. ~ Your doctor c:ln usc the list associated with your chosen option to select medications for your he;lhhcarc needs, while helping you maximize your prescription drug bendit.The choice of medications is strictly between you and your doctor. ~ Preferred Drug LislS for the SHBP members are subjeel to change. Prior co purchasing your medkation(s) y011 may view the drug lists at www.dch.st:Lle.ga.usorcontact Express Scripts by phone:1( (Rn) 65()-9j42 orTDD (800) 842-5754 to gel the most current st;ltUS on any covered drug. On the following pages is an abbre\'iau:d v(. rsion of the two drug lists for comparison. Use these lists to help rou determine what yOllr co-payments will he and to evaluate which drug benefit will beSt meet rour needs. GEORGIA BASIC PREFERRED DRUG LIST (ABBREVIATED) EFFECTIVE JULY 1, 2004 FOR STATE HEALTH BENEFIT PLAN - PPO AND INDEMNITY HEALTH PLANS All generics are considered preferred drugs (cxampks listed in each category). If at any time during the Plan year a brand has a generic equivalent become available, that brand \vill automatically be moved to the non-prd't:rrnl status. KH PA _ prior authorization re~uired QLl - quantity or therapy limits exist ALLERGY!RESPIRATQRY ADVAIR DI$KUS, Qtt albuterol generic, Qtt f\LLEGRA, -0, Qtt COMBIVENT, Qtt FlOVENT ROTADISK, QI.L FORArJIL, QLl INTAL, Qtt ipratrolJium gerleric, Qtt PROV NTIL HFA, Qtt QVAR, QU. SEREVENT DISKUS, Qtt SINGULAIR ANTIINFECTIVES Jcyclovir gClwric ,tnlOxicillin generic C1moxicillinldavulanic generic ,unpicillin generic AUGMENl'IN ($ AUG.'v\NTlN XI{, QLL AV[lOX, ABC PACK cefllroxime generic cephJJcxin generic C1PRO LJnUCAN, PA doxvcycline generic erylhrofllycirl generic keloconJ7.01c gcneric nilroiurrl,llain generic penicillin generic SrORANOX, QLl. lOA TEQUIN tetracycline genl'ric lilllelhoprim generic tmp/smx gerlCric ZITHROMAX AUTONOMIC & CNS AMIlIEN, QLl Jmitriptyline generic CELEXA CONCERTA rlexlroamphelamine generic f'AJge> 11 EfHXOR, -XR f1uoxeline generic IMITREX. ()LL LUAI-'RO MET/\D/\TE CD lJlelhylphenicbte generic rllirtnJpine generic pJfQxetlnc generic I-',\XIL CR REMERON soltJb SONATA. QU. STRATTERA Il'mazepam generic tr<, n't'" rill/('Ill of CrJIIlI!ll1!! II)' }-Jc"IIIJ. GEORGIA PREMIER PREFERRED DRUG LIST (ABBREVIATED) EFI'IOCTIVE JULY 1, 2004 FOR STATE HEALTH BENEFIT PLANS - PPO AND INDEMNITY HEALTH PLANS AU j.:cncrics arc considcrt:d prdcrn:d drugs (examples listed in !.-'lell cau:gory).lf:1( any lime during the Plan year a br.uuf h:L<; a generic equiv';.l!clll be...-come :n';liJahle, that brand will autOm:uically be movnl to the non-preferred status. KfY PA - prior authorization reljuired Qtl - quantity or therapy limits exist ALJ.ERGY/RF.SPIRATORY ADVAIR OISKUS, QLI dlbulCl'ol generic, Qt.l AllEGRA, -il, Qt.l COMHtVEI\.T, Qtl cromolyn sodium generic FLOVENT, -ROTADISK. Qll FORADll. QU. ipr~tropillm generic. QLl MAXAIR AUTO' IAI.ER, QLt mCI;Jprorcrcoolllcncric. QtL PROVENTIL HFA, Qtl PUL\t\ICORT RESPUL(S, QLl SINGULAIR TlLADE, Qll ZVRTEC, Qll ANTI-INFECl'IVES 'llyclovir generic amlJxicillirl generic amoxkillin/c1,l\Iul.lnic generic ampicillin gcncril AUGMENT" ER AUG.'.IE1\'TIN X~, Qll AVELOX ccfuroxime gCI'IC.>fic CEFZll cephalexin generic CIPRO CIPRO XR, QlL DIFlUC,\N 150...tG, QLl DIFtUCAr-., PA doxycyclirw; generk. erythromyCIn genC'f1C GANTRISIN PEDIATlUC grb;cofulvin gcnl>fic I{eloconilzole gelll..>fic LAMISI1, P/\ MACROlllD penicillin generil: SPECTRACEF SPQRANOX Qll, P,\ lelrilcycline generiC Ifl1JYsm)( generic VALTR[)(, Qtl lITHROMAX AUTONOMIC & eNS ADDERALI XR, PA age >2 I Jlprawlilnl generic AMIlIEN, QLL amitripTyline gCrlC'fk bupropion generic buspirooe generic CONCERTA desiPfamine generic de)(lro.lmphe!amme generic, PAage>21 dial.('pilm generil EfFEXQR, .. XR fluoxclinc generic imipramine generic lMITREX, Qtt LEXAPRO IOfazcpam generic MIGRANAl, Qtt nortriplrlinc generic oxal.qJam generic paroxCline generic Irazodonc generic lriazul.lm generic WHlBUTRIN..Xl lOtOH lOMIG, -ZMT, Qtt GASTROINTESTINAL ASACOt AZUlFID1NE EN,TAB cimctidine generic far'lotiuine generic omeprazule generic QLL, PA PANCREASE pancrelipase generic PEr-.'iASA PREVACID QlL PA PREVPAC, Qtl PIl:QCTOFOAM-HC ranitirlinc generic ROWASA ,ucralf.lle generic UI<:SO VIOKASE ZANTAC SYRUP CARDIOVASCULAR ADVICOR AtTACE alcnolol generic henazepnl generic ben.ll.eprililictz ger'lcric (,lploprd generic CARDIZEM lA CATAPRES-rrs, QLl chol('Slyraminc generic COREG COZAAR dil!iilzem, sa generic OIOVAN. -ITCT en,11.1pril generic furosemide generic gem/ibro?il gwerir. Fiydrochlorothaizide generic 11YZAAR LEVATOl tEXXEl lIPITOR liSlnopril generic Iislflopril wihdz generic lOTREL IOVilst,ltin generic mClOl.lzonc gerleric meloprulol generic NIASPAN nicarrlipine generic lli(edipmc. cr, xl generic NIMOTOt> r-.ORVASC PI<:AVACHOt prazosin generic propr,lnorol generic spironolactone generic lcrawsin gem'ric TOI'ROL Xl IOfscmirle gCrlt'lic TRrCOR vcrTING tOR NON-PREHRR(() BRANDS NON-PREfERRED BRAN!) SHlCTEO ALTERNATII/E BRANDS Aceon. ben,n(,'pril. lisinopril, Ahace Aciphex . . . . olneprazole, Pr('Vacid Accolate . . . , .. Singulair Accupri! , , . bcnazeprit lisinopril, AllilCl' Adillclla ....... , . _ .. f'rempro, ~razolc, PreYa<:id J Plendil. . . . . . nilf"dipine, Norvasc Prolonix . . . . omeprazole, Prevacid PulmiOOI1., - ... " . - . , ,. .. -". Flovent Screvenl , . . Faradil Sular . . nife'<.1ipine. Norvasc Tcvelen , .. , _Cozaar, Diol/i1n for Prior AUlhorizalions (PA), Quantity ~cl1lmi1S (Qtl.) or .11)' queslions rq;arding spL"Cifk CO"Cr:>gc:: ruk:-!; or ro--p")'In~m inform:,,;on for dnll!lS nOI Lisle Yes Y", Not Available CIG~A yO' Not Available Yes Not Available Yes Yes Not Available Not Amilablc Ye, Yes Not Available Y", Yes Yes Ye, Yes Not Available Yes Yes Not Availahle Yes Yes Yes Yes Not Available KAISER PER\tA:"iE:"1TE Not Available Not Available Not Available Not Avail:lble Ye, Ye, Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available NOI Available Not Available Not Available Not Available Not Available.: Yes Not Avail::tble Ye, NOt A\':tilable UStTED H E,\lTHC.4.RE Yes '1'<':5 Yes Yes Yes Yes Yes Yes yO' Y", Yes Yes Yes Yes Yes Yes Y", Yes Yes Yes Yes Yes Yes Yes Yes COUN1Y OF RESIDENCE Cohh Colquitt Columbia Cook Cowcta Cmwford O:lde Dawson Dee:llur OeKalb Douglas Early Echols Effingham Bbert Emanuel Evans Fayette floyd Forsyth Franklin Fulton Gilmer Glascock Gordon Grady Greene GwinnClt Habersham Hall Harris Hart Hc...-ard Hcnf)' BI.Uf.CnQICE Yes Not Available Yes Not Available Yes Yes Not Available Yes Not Available Yes Yes Not Available NOI Av'.tilablc Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yc...os NOI Available Yes Yes NOI Availabk Yes Yes Yes Yes Yes CIGNA Yes Not Avail:tble Yes Not t\\>ailable Yes Not Available Yes NOI Av".tilable NOt Available Yes Yes Not Available Not A\'":tilablc Y~ Yes Yes Yes Ycs Yes Yes Ycs Ye~ 1"101 Avail.1bk Not Avail:lbk Yes 1"101 Available Yes Yes Not Available Yes Yes Not A\'ail:lble Not A\-ailable Yes K,\ISER PERMANENTF. Ycs Not Available Not Available NOI A\-ailable Yes Not A\'ailable NOI A\'ailable NOl Available NOI Available Yes Yes Not Available Not Available Not A\':tilable Not Available NOI Availablt: Not Available Yes Not Available Yes Not Available Yes Not A\-ailable Not Available Not Available 1"101 A\rtilablc 1"101 Available Yc..."S Not Available Yes Not Available Not Available Not Available Yes UNlTEDHF.ALTlICARE Yes Yes Yes Yes y"" Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yc...os Ycs Ycs Yes Yes Not Available Yes Nm Available Yes y~ Yes Yes Yes Ycs Yes Yes Not Available 1"101 A\-ailabJc Yes COUNTY OF RESIDENCE HOUSlOn jackson jasper jefferson jenkins johnson jones L1mar lmlier I..:lllrellS Libelly lincoln Long Lowmk-s Lumpkin Madison Marion McDuffie Meriwcther Mitchell Monroe Morgan l\'luscogtt Newton Oconee Oglethorpe Paulding hadl Pickens Pierce Pike Polk Pulaski Putnam 8LUECnOlCl' Yes Yes Not A\'ailable Yes Yes Yes Yes Not Available Not Availabk Not Available Yes Yes NOI Available Not Available Yes Yes Y<~ Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Not Available Ycs Yes NmAvailablc CIGNA Not AV'::lilablc Yes Not A\':lilable Yes Not A\-ailabk Not Available Yes Yes Not Available Yes Yes Yes Yes Not A\re-existing condition limitation does not apply to coverage for: ~ Pregnancy; Of ~ Newborns or children under age 18 who are adopted or placed for adoplion. if the child becomes covered widlin 31 days after birth, adoplion or placemem for adoption. In cerlain situations, SHBP members and dependents can reduce the 12-mOlllh pre-existing condition limitation period. The reduction is possible by using what is called ~credit'able coverage" to offset a pre-exisling condilion period, Creditable coverage generall)' includes the health coverage yOll or a f:mlily member hOld immediately prior (0 joining the SIIBP Cover:lge undc.:r most group healtll plans. as well as coverage under individual health policies and gO\'emmelllal health programs, qualifies as creditable covernge. To redu<:c the pre-existing condition Iimilalion period for your own covemge, you m1lst provide the SHIlP with a certificate of credit:lble coverage from one or more former heahh pbns or insurers that states when rour prior covernge staned and endcd.Any period of prior Covcr:lge will reduce the 12-month limitation period if the limt: between losing coverage and your first da)' of SHBP covemge does nUl exceed 63 days. If you are enrolling as a new hire, the 63-day period is nH;:asured from your last day of prior cover:lge up 10 your dale of hire. To reduce the prc-cxisling condition Limil