PPO/indemnity health benefits comparison chart, plan year 2004

"Creating a More Educated Georgia"

for smooth sailing toward the Healthcare plan that's right for you.
PPO/Indemnity
Health Plans Comparison Chart
Board of Regents of the University System of Georgia PLAN YEAR 2004

PPO&Indemnity Plan Options for 2004

Page 2 University System of Georgia 2004 PPO and Indemnity Health Plan Options

The University System of Georgia offers a PPO/PPO Consumer Choice healthcare plan option and an indemnity healthcare plan option. We strongly encourage plan participants to use network providers to minimize member out-of-pocket expenses. For Plan Year 2004, the University System of Georgia will implement a four-tier premium structure. The four tiers will be designated as "Employee", "Employee + Child," "Employee + Spouse", and "Family." If you were enrolled in the "Employee + One" category for Plan Year 2003, you will be required to select the appropriate level of healthcare coverage for Plan Year 2004.
The 2004 annual Open Enrollment period for the University System of Georgia is scheduled for October 14, 2003, through November 14, 2003. You will not be required to make a formal election of a healthcare plan for Plan Year 2004 unless you wish to change your plan type or change your level of healthcare coverage. To assist you in making this decision, the Board of Regents has prepared information booklets that compare the different types of plan coverage for the PPO healthcare plan, the indemnity healthcare plan, and the HMO healthcare plans, where available. The University System Office has prepared two separate information booklets: (1) PPO/Indemnity Health Plans Comparison Chart, and (2) HMO Healthcare Plans Comparison Chart.
For Plan Year 2004, please be informed that the name for the Georgia PPO/PPO Consumer Choice network has changed from MRN/Georgia 1st, to 1st Medical Network. For Plan Year 2004, there will be one plan design change for the indemnity healthcare plan. The "Outpatient Short Term Rehabilitation Services" benefit for the indemnity healthcare plan will change to be consistent with this benefit for the PPO/PPO Consumer Choice healthcare plan. For both of these healthcare plans, physical therapy, occupational therapy, cardiac therapy, and speech therapy will be limited to 40 visits per incident type per plan year.
For Plan Year 2004, there will be a number of changes made to the pharmacy benefit management program. The member co-payment for a generic prescription medication will remain at $10; the member co-payment for a preferred brand name medication will increase from $20 to $25; and the member co-payment for a non-preferred brand name medication will increase from a $35 minimum/$70 maximum, to a $40 minimum/$100 maximum. There will also be a change from a "monthly" out-of-pocket maximum to a "quarterly" out-of-pocket maximum for those members who obtain generic and

preferred brand name medications. Additional information is provided in the health plans

comparison chart.

We wish to share with you an important piece of legislation that was passed during the

2003 session of the Georgia General Assembly. House Bill 721 requires that health insurance

identification cards issued by an insurer on or after July 1, 2004, shall not display the contract

holder's social security number for any purpose, or in any manner. The University System of

Georgia will require that a unique number be established for each healthcare plan contract

holder as of January 1, 2004.

Please be reminded of the following statutory requirement passed by the 2002 session of

the Georgia General Assembly. Members who participate in a managed healthcare plan are

hereby advised of the following limitation: "For reimbursement, your healthcare plan may

restrict the choice of who may treat you or your family and, where you may

be treated." Please be informed that the PPO/PPO Consumer Choice

PPO PPO PhPeaOlthcParPe OplanPanPdOthe two HMO healthcare plans are deemed to be

O PPO PPO PmPaOnagPedPhOealthPcParOe plans.

PPO



PPO



PPO



PPO



PPFoOr

additional


information,

please

consult

with

your

O PPO PPO PPO PPcOampPuPs OHuman Resources department. We are pleased

PPO PPO PPO PPO PPOtoshare the following information that affects a

O PPO PPO PPO PPO PPOcritically important aspect of everyone's life --

PPO PPO PPO PPO PPO

his or her health. Please review the infor-

O PPO PPO PPO PPO PPO

mation presented and select the

PPO PPO PPO PPO PPO

healthcare plan option that

is best for you and

O PPO PPO PPO PPO PPO

your family.

PPO PPO PPO PPO PPO

O PPO PPO PPO PPO PPO

PPO PPO PPO PPO PPO

PPO& Indemnity Healthcare Premiums

Indemnity Plan

Preferred Provider Option (PPO) Preferred Provider Option (PPO)
with Consumer Choice Option

Page 3 University System of Georgia 2004 PPO and Indemnity Health Plan Options

Plan Year
Employee Only
Employee Employer Total Rate
Employee + One
Employee Employer Total Rate
Employee Employer Total Rate
Family
Employee Employer Total Rate
Retiree (with Medicare)
Employee Employer Total Rate
Retiree + One
(both with Medicare) Employee Employer Total Rate

2003
$110.38 $331.12 $441.50
$209.58 $628.76 $838.34
$309.24 $927.68 $1,236.92
$59.88 $179.64 $239.52
$119.76 $359.28 $479.04

2004
$112.56 $337.66 $450.22
+ Child
$202.60 $607.80 $810.40
+ Spouse
$236.38 $709.10 $945.48
$326.42 $979.24 $1,305.66
$65.88 $197.60 $263.48
$131.76 $395.20 $526.96

2003
$68.40 $205.22 $273.62
$129.88 $389.62 $519.50
$191.64 $574.86 $766.50
$37.12 $111.32 $148.44
$74.22 $222.64 $296.86

2004
$72.32 $216.92 $289.24
+ Child
$130.16 $390.48 $520.64
+ Spouse
$151.86 $455.56 $607.42
$209.70 $629.10 $838.80
$40.84 $122.44 $163.28
$81.68 $244.88 $326.56

2003
$95.76 $205.22 $300.98
$181.84 $389.62 $571.46
$268.30 $574.86 $843.16
$51.96 $111.32 $163.28
$103.92 $222.64 $326.56

2004
$101.26 $216.92 $318.18
+ Child
$182.24 $390.48 $572.72
+ Spouse
$212.62 $455.56 $668.18
$293.60 $629.10 $922.70
$57.18 $122.44 $179.62
$114.36 $244.88 $359.24

Schedule of Selected Benefits

Page 4 University System of Georgia 2004 PPO and Indemnity Health Plan Options

Comparison of University System of Georgia Indemnity and PPO Healthcare Plan Options Effective January 1, 2004

Indemnity Plan

Preferred Provider Option

Preferred Provider Option

Preferred Provider Option

(PPO) Plan, Georgia In-Network (PPO) Plan, National In-Network (PPO) Plan, Out-of-Network

COVERED SERVICES

Healthcare Plan Vendors

Blue Cross Blue Shield of Georgia, Inc.

1st Medical Network

Beech Street Corporation

Description of Plan

Major medical coverage, including diagnosis and/or treatment of illness, injury or medical conditions. Benefits include physician, hospital, surgical, disease state management, pharmacy benefit management, mental health/ substance abuse and transplant services.
When a member requires medical care/services, he/she can elect to see providers who are not in the Blue Cross Blue Shield of Georgia (BCBSGA) Participating Provider Program or in the Blue Cross Blue Shield (BCBS) National Participating Provider Network.
Failure to access these BCBS networks or programs will result in the member being subject to balance billing.

Major medical coverage, including diagnosis and/or treatment of illness, injury or medical conditions. Benefits include physician, hospital, surgical, disease state management, pharmacy benefit management, behavioral health (mental health/substance abuse) and transplant services.

Major medical coverage, including diagnosis and/or treatment of illness, injury or medical conditions. Benefits include physician, hospital, surgical, disease state management, pharmacy benefit management, behavioral health (mental health/substance abuse) and transplant services.

Major medical coverage, including diagnosis and/or treatment of illness, injury or medical conditions. Benefits include physician, hospital, and surgical services.
When a member requires medical care/services, he/she can elect to see providers who are not in the PPO network.
Members who elect to use the services of out-of-network doctors and hospitals will receive a lower level of benefit coverage.
Members who elect to use the services of out-of-network doctors and hospitals will be subject to balance billing.

Providers of Medical/Pharmacy
Benefit Management Services
(UNICARE administers the MedCall, Inpatient and Outpatient Hospital
Pre-Certification, Disease State Management and
Transplant Services programs.)

Blue Cross Blue Shield of Georgia (BCBSGA) has established the BCBSGA Participating Provider Program to minimize a member's out-of-pocket expenses for covered physician charges provided within the state of Georgia.
Blue Cross Blue Shield (BCBS) has established the BCBS National Participating Provider

For Plan Year 2004, the Georgia Network will now be designated as 1st Medical Network, rather than as MRN/Georgia 1st.
The 1st Medical Network includes more than 13,000 physicians; 168 hospitals and ancillary providers; and a comprehensive chiropractic network.

The Beech Street National PPO network includes more than 358,000 physicians; 3,400 hospitals and 50,000 ancillary providers; and a comprehensive chiropractic network.
The service area for the Beech Street National PPO network includes all zip codes located within the United States, other

Members who elect to use the services of out-of-network medical providers will be subject to balance billing.
Members who elect to use the services of out-of-network pharmacies will be subject to balance billing.

(Express Scripts administers the Pharmacy Benefit
Management program.)
Member costs incurred for balance billing will not
apply toward the annual deductible or toward the
annual out-of-pocket limits (stop loss).
Providers of Behavioral Health
Services
(Mental health and substance abuse)

Network to minimize a member's out-of-pocket expenses for covered physician and facility charges provided outside of the state of Georgia.
Failure to access these BCBS networks or programs will result in the member being subject to balance billing.
The provider directory for the BCBSGA Participating Provider Program and for the BCBS National Participating Provider Network is available at www.usg.edu/admin/humres/ benefits/health/.
Access to Behavioral Health Services for members within the state of Georgia will be facilitated through the BCBSGA Prudent Buyer Program.
Access to Behavioral Health Services for members outside of the state of Georgia will be facilitated through the BCBS National Participating Provider Network.
There is no annual out-of-pocket limit for Behavioral Health Services.
Pre-certification is required by UNICARE.

The service area for the 1st Medical Network PPO network includes all zip codes located within the state of Georgia. The 1st Medical Network also includes Russell County, AL; Bradley County, TN; and Hamilton County, TN.
The 1st Medical Network PPO Provider Directory is available at www.healthygeorgia.com.

than those identified for the 1st Medical Network PPO network.
If a member uses a Beech Street provider that is located within the Georgia In-Network (1st Medical Network) service area, the provider will be considered to be out-of-network.
The Beech Street National PPO provider directory is available at www.healthygeorgia.com.

The University System of Georgia uses the Magellan Behavioral Health, Inc. national network of physicians, healthcare professionals and hospitals for mental health and substance abuse services at discounted rates.
Magellan provides 24 hour, toll-free telephone access to clinical assessment and referral services for treatment/care of mental health/ substance abuse conditions.
The annual out-of-pocket maximum (stop loss) is $2,500 per patient per plan year for Magellan-referred network care.
Pre-certification is required by Magellan.

Not applicable.

Page 5 University System of Georgia 2004 PPO and Indemnity Health Plan Options

Schedule of Selected Benefits continued next page

Page 6 University System of Georgia 2004 PPO and Indemnity Health Plan Options

Indemnity Plan

Preferred Provider Option

Preferred Provider Option

Preferred Provider Option

(PPO) Plan, Georgia In-Network (PPO) Plan, National In-Network (PPO) Plan, Out-of-Network

PLAN DESIGN FEATURES

Pre-Existing Conditions None

None

Max. Lifetime Benefit
Amount of Coverage
Max. Annual Deductible
(Family = 3 or more covered members)

$2 million

$2 million

$300 -- Individual Maximum $900 -- Family Maximum

$300 -- Individual Maximum $900 -- Family Maximum

$400 -- Individual Maximum $1,200 -- Family Maximum

Annual deductibles and annual out-of-pocket limits (stop loss) will be based on a January 1 to December 31 plan year. Member costs incurred for balance billing WILL NOT apply toward the annual deductible(s) or toward the maximum annual out-of-pocket (stop loss) limit(s).

Max. Annual Out-ofPocket (Stop Loss)
(Family = 3 or more covered members)

$2,000 -- Individual Maximum $4,000 -- Family Maximum
Indemnity Members: Member co-payments for prescription drugs do not apply toward the annual deductible or the maximum annual out-of-pocket (stop loss) limits.

$1,000 -- Individual Maximum $2,000 -- Family Maximum

$2,000 -- Individual Maximum $4,000 -- Family Maximum

We encourage PPO participants to use in-network providers. Members who use both Georgia network (1st Medical Network) providers and out-of-network providers will be responsible for two separate deductibles and for two separate maximum out-of-pocket limits (stop loss). Member deductibles and stop loss limits for a member who uses National network (Beech Street) providers will be combined with the out-of-network deductible and the out-of-network stop-loss limit. This means that the covered expenses for a member who uses both National network (Beech Street) providers and out-of-network providers will be a combined $400/individual and $1,200/family maximum deductible and/or a combined $2,000/individual and $4,000/family maximum stop-loss limit.

PPO/PPO Consumer Choice Members: Member co-payments for physician office visits, emergency room services and/or prescription drugs do not apply toward the annual deductible or the maximum annual out-of-pocket (stop loss) limits.

PHYSICIAN SERVICES PROVIDED IN OFFICE SETTING

Physician Office Visit
(For treatment of illness or injury)

80% of UCR charges for nonsurgical services; subject to deductible.

100% of network rate after a $20 co-payment per visit; applies to non-surgical services; not subject to deductible.
The $20 co-payment applies to the physician's office visit only.
The $20 co-payment does NOT apply to covered charges associated with medical treatment/services. (Medical treatment/services may include services such as X-rays, laboratory tests and diagnostic tests.)

100% of network rate after a $20 co-payment per visit; applies to non-surgical services; not subject to deductible.
The $20 co-payment applies to the physician's office visit only.
The $20 co-payment does NOT apply to covered charges associated with medical treatment/services. (Medical treatment/services may include services such as X-rays, laboratory tests and diagnostic tests.)

60% of network rate for non-surgical services; subject to deductible and balance billing.

Wellness Care/ Preventative Health Care
Physical Exam, Pap Smear, Prostate Exam/PSA,
Mammogram, Well-Baby Care/Immunizations, Adult Immunizations, Routine Eye Exams,
Routine Hearing Exams
Laboratory Services
(Exclusive of Wellness Care/ Preventative Health Care) Pre-certification for diagnostic testing may be required by UNICARE.
Maternity Care
(Prenatal, Delivery and Postnatal)
Outpatient Surgery
Pre-certification may be required by UNICARE.
Second Surgical Opinions
(Elective Surgery)
Allergy Testing
Allergy Shots & Serum
Treatment of TMJ
(Temporomandibular Joint Disorders)
Diagnostic testing & non-surgical treatment Pre-certification may be
required by UNICARE.

$500 per person per plan year; paid at 100% of UCR; not subject to deductible.
The maximum wellness benefit that a covered member may receive is $500 per person per plan year, regardless of the network affiliation of the provider.

$500 per person per plan year; paid at 100% of network rate; not subject to deductible.
$20 co-payment per office visit. The maximum wellness benefit that a covered member may receive when using Georgia and/or National In-Network providers is $500 per person per plan year.

$500 per person per plan year; paid at 100% of network rate; not subject to deductible.
$20 co-payment per office visit. The maximum wellness benefit that a covered member may receive when using Georgia and/or National In-Network providers is $500 per person per plan year.

Not covered. Non-covered charges do not
apply to annual deductible or annual out-of-pocket maximum.

80% of UCR charges; subject to deductible.

90% of network rate; subject to deductible.

80% of network rate; subject to deductible.

60% of network rate; subject to deductible and balance billing.

Laboratory, X-ray, allergy testing, injectible medications and diagnostic tests. Injectible medications that are provided in a physician's office may be covered under medical benefits.

90% of UCR charges; subject to deductible.
90% of UCR charges; subject to deductible.

90% of network rate after an initial visit co-payment of $20; not subject to deductible.
There will be no co-payments charged for subsequent visits.
90% of network rate; subject to deductible.

80% of network rate after an initial visit co-payment of $20; not subject to deductible.
There will be no co-payments charged for subsequent visits.
80% of network rate; subject to deductible.

60% of network rate; subject to deductible and balance billing.
60% of network rates; subject to deductible and balance billing.

100% of UCR charges; not subject to deductible.
80% of UCR charges; subject to deductible. 80% of UCR charges; subject to deductible.
80% of UCR charges; subject to deductible.
Lifetime benefit limit of $1,000.

100% of network rate after a $20 co-payment per visit; not subject to deductible.
90% of network rate; subject to deductible.
100% for allergy shots & serum; not subject to deductible.
If a physician is seen, the visit is treated as an office visit and is subject to a $20 co-payment per visit.
90% of network rate; subject to deductible.
Lifetime benefit limit of $1,100.

100% of network rate after a $20 co-payment per visit; not subject to deductible.
80% of network rate; subject to deductible.
100% for allergy shots & serum; not subject to deductible.
If a physician is seen, the visit is treated as an office visit and is subject to a $20 co-payment per visit.
80% of network rate; subject to deductible.
Lifetime benefit limit of $1,100.

60% of network rate; subject to deductible and balance billing.
60% of network rate; subject to deductible and balance billing. 60% of network rate; subject to deductible and balance billing.
60% of network rate; subject to deductible and balance billing.
Lifetime benefit limit of $1,100.

Page 7 University System of Georgia 2004 PPO and Indemnity Health Plan Options

Page 8 University System of Georgia 2004 PPO and Indemnity Health Plan Options

Indemnity Plan

Preferred Provider Option

Preferred Provider Option

Preferred Provider Option

(PPO) Plan, Georgia In-Network (PPO) Plan, National In-Network (PPO) Plan, Out-of-Network

INPATIENT HOSPITAL SERVICES

Physician Services Physician Care/ Surgery
Physician services may include surgery, anesthesiology, pathology,
radiology and/or maternity care/delivery Pre-certification is required
by UNICARE.
Hospital Services Other Than Those for Emergency Room Care
Inpatient Care (Includes inpatient short-term
rehabilitation services) Pre-certification is required
by UNICARE.
Maternity Care
(Delivery)
Laboratory Services
Pre-certification for diagnostic testing may be required by UNICARE.

90% of UCR charges for surgeon; subject to deductible.
80% of UCR charges for anesthesiologist, pathologist, or radiologist services/consultations; subject to deductible.
Some surgeons and/or some hospital-based physicians (examples: emergency room physicians, anesthesiologists, pathologists and/or radiologists) providing services may not be a part of the BCBSGA Participating Physician Program/BCBS National Participating Provider Network.
Failure to access these BCBS networks or programs will result in the member being subject to balance billing.

90% of network rate; subject to deductible.
Some hospital-based physicians (examples: emergency room physicians, anesthesiologists, pathologists, and/or radiologists) providing services may not be a part of the network.
Services provided by non-network physicians will be covered at 60% of the network rate; subject to out-of-network deductible and balance billing.

80% of network rate; subject to deductible.
Some hospital-based physicians (examples: emergency room physicians, anesthesiologists, pathologists, and/or radiologists) providing services may not be a part of the network.
Services provided by non-network physicians will be covered at 60% of the network rate; subject to out-of-network deductible and balance billing.

60% of network rate; subject to deductible and balance billing.

In-State Hospitals 90% of contracted DRG rate; limited to semi-private room; subject to deductible.
Out-of-State Hospitals 90% of UCR for service area; limited to semi-private room rate; subject to deductible.
The use of a non-BCBS National Participating Provider Network facility outside of the state of Georgia will result in benefit coverage at 90% of contracted state of Georgia DRG rate; subject to deductible and balance billing.

90% of contracted DRG rate; limited to semi-private room; subject to deductible; not subject to balance billing.
The 1st Medical Network service area includes all zip codes located within the state of Georgia. The 1st Medical Network also includes Russell County, AL; Bradley County, TN; and Hamilton County, TN.

80% of network rate; limited to semi-private room; subject to deductible; not subject to balance billing.
The Beech Street national PPO network service area includes all zip codes located within the United States, other than those identified for the 1st Medical Network PPO network.

60% of contracted state of Georgia DRG rate; subject to deductible and balance billing.

90% of contracted DRG rate; subject to deductible.

90% of contracted DRG rate; subject to deductible.

80% of network rate; subject to deductible.

60% of contracted state of Georgia DRG rate; subject to deductible and balance billing.

90% of UCR charges; subject to deductible.

90% of network rate; subject to deductible.

80% of network rate; subject to deductible.

60% of network rate; subject to deductible and balance billing.

X-ray, lab work, diagnostic testing provided in conjunction with treatment of illness or injury.

Hospice Care
Pre-certification is required by UNICARE.

90% of UCR charges; subject to deductible.

100% of network rate; subject to deductible.

100% of network rate; subject to deductible.

60% of network rate; subject to deductible and balance billing.

Page 9 University System of Georgia 2004 PPO and Indemnity Health Plan Options

OUTPATIENT HOSPITAL/FACILITY SERVICES

Physician Services Physician Care/ Surgery
Physician services may include surgery, anesthesiology, pathology,
radiology and/or maternity care/delivery Pre-certification is required
by UNICARE.
Facility Selected by Treating Physician
Treatment/care provided in an outpatient setting may require pre-certification by UNICARE.

90% of UCR charges for surgeon; subject to deductible.
80% of UCR charges for anesthesiologist, pathologist or radiologist services/consultations; subject to deductible.
Some surgeons and/or some hospital-based physicians (examples: emergency room physicians, anesthesiologists, pathologists and/or radiologists) providing services may not be a part of the BCBSGA Participating Physician Program/BCBS National Participating Provider Network.
Failure to access these BCBS networks or programs will result in the member being subject to balance billing.
90% of UCR charges in a Plan approved facility; subject to deductible.
Failure to use a Plan approved facility will result in the member being subject to balance billing.
For identification of a Plan Approved Facility within the state of Georgia, please contact BCBSGA Customer Service at 1-800-424-8950/ TDD 404-842-8073.
For identification of a Plan Approved Facility outside the state of Georgia, please contact BCBS Customer Service at 1-800-810-BLUE (2583).

90% of network rate; subject to deductible.
Some hospital-based physicians (examples: emergency room physicians, anesthesiologists, pathologists and/or radiologists) providing services may not be a part of the network.
Services provided by nonnetwork physicians will be covered at 60% of network rate; subject to out-of-network deductible and balance billing.
90% of network rate; subject to deductible.
Some facilities selected by a treating physician may not be a part of the network.
Services provided at non-network facilities will be covered at 60% of the network rate; subject to out-of-network deductible and balance billing.
The1st Medical Network PPO provider and facility directory is available at www.healthygeorgia.com.

80% of network rate; subject to deductible.
Some hospital-based physicians (examples: emergency room physicians, anesthesiologists, pathologists and/or radiologists) providing services may not be a part of the network.
Services provided by nonnetwork physicians will be covered at 60% of network rate; subject to out-of-network deductible and balance billing.
80% of network rate; subject to deductible.
Some facilities selected by a treating physician may not be a part of the network.
Services provided at nonnetwork facilities will be covered at 60% of the network rate; subject to out-of-network deductible and balance billing.
The Beech Street National PPO provider and facility directory is available at www.healthygeorgia.com.

60% of network rate; subject to deductible and balance billing.
60% of network rate; subject to deductible and balance billing.

Page 10 University System of Georgia 2004 PPO and Indemnity Health Plan Options

Indemnity Plan

Preferred Provider Option

Preferred Provider Option

Preferred Provider Option

(PPO) Plan, Georgia In-Network (PPO) Plan, National In-Network (PPO) Plan, Out-of-Network

OUTPATIENT HOSPITAL/FACILITY SERVICES CONTINUED

Care in a Hospital Emergency Room
(ER)
(Treatment of an emergency medical condition or injury)

Surgical Services 90% of UCR charges, if referred by MedCall; subject to deductible.
80% of UCR charges, if not referred by MedCall; subject to deductible.
Non-Surgical Services 80% of UCR charges, if referred by MedCall; subject to deductible.
70% of UCR charges, if not referred by MedCall; subject to deductible.

90% of network rate after a $75 co-payment per visit; subject to deductible.
Co-payment is reduced to $50, if referred by MedCall. Co-payment is waived, if admitted within 24 hours.

90% of network rate after a $75 co-payment per visit; subject to the 1st Medical Network in-network deductible.
Co-payment is reduced to $50, if referred by MedCall. Co-payment is waived, if admitted within 24 hours.

90% of network rate after a $75 co-payment per visit; subject to the 1st Medical Network in-network deductible; subject to balance billing.
Co-payment is reduced to $50, if referred by MedCall. Co-payment is waived, if admitted within 24 hours.

Laboratory Services
Pre-certification for diagnostic testing may by
required by UNICARE.
Urgent Care Services
Home Nursing Care
Pre-certification is required by UNICARE.
Extended Care Facility
Pre-certification is required by UNICARE.

80% of UCR charges; subject to deductible.

90% of network rate; subject to deductible.

80% of network rate; subject to deductible.

60% of network rate; subject to deductible and balance billing.

X-ray, lab work, diagnostic testing provided in conjunction with treatment of illness or injury.

80% of UCR charges; subject to deductible.

90% of network rate after $20 co-payment per visit; subject to deductible.

80% of network rate after $20 co-payment per visit; subject to deductible.

60% of network rate; subject to deductible and balance billing.

90% of UCR charges; subject to deductible. No plan year limit.

90% of network rate; limited to 2 hours of care in a 24-hour day; subject to deductible.
In lieu of hospitalization and with approval by UNICARE, additional benefits may be allowed.
Charges do NOT apply to annual out-of-pocket maximum.
Benefit limit of $7,500 per member per plan year; plan approved Letter of Medical Necessity required.

80% of network rate; limited to 2 hours of care in a 24-hour day; subject to deductible.
In lieu of hospitalization and with approval by UNICARE, additional benefits may be allowed.
Charges do NOT apply to annual out-of-pocket maximum.
Benefit limit of $7,500 per member per plan year; plan approved Letter of Medical Necessity required.

60% of network rate; limited to 2 hours of care in a 24-hour day; subject to deductible and balance billing.
In lieu of hospitalization and with approval by UNICARE, additional benefits may be allowed.
Charges do NOT apply to annual out-of-pocket maximum.
Benefit limit of $7,500 per member per plan year; plan approved Letter of Medical Necessity required.

90% of UCR charges; subject to deductible.

Not available.

Not available.

Not available.

An extended care facility is a skilled nursing facility qualified to receive Medicare payments or one that operates in accordance with local laws under the full-time supervision of a licensed nurse or doctor. It must provide room and board and 24-hour-a-day skilled nursing care of sick and injured persons at the patient's expense during the convalescent stage of an injury or illness. Extended care facilities do not include an institution operated primarily for the care of the aged, treatment of mental disease, drug addiction, alcoholism, educational or custodial care.

Home Hyperalimentation
Pre-certification is required by UNICARE.
Hospice Care
Pre-certification is required by UNICARE.

90% of UCR charges; subject to deductible. No lifetime benefit limit.
90% of UCR charges; subject to deductible.

Cochlear Implants
Pre-certification is required by UNICARE.
Ambulance Services
For medically necessary emergency transportation
only
Durable Medical Equipment
Vendor: UNICARE.
Outpatient Short-Term Rehabilitation Services
Pre-certification is required by UNICARE.
Chiropractic Care

90% of UCR charges; subject to deductible.
80% of UCR charges; subject to deductible.
80% of UCR charges; subject to deductible.
80% of UCR charges; subject to deductible.
Physical, speech, cardiac and occupational therapies are limited to 40 visits per incident type per plan year. Not available.

90% of network rate; subject to deductible.
Lifetime benefit limit of $500,000.
100% of network rate; subject to deductible.
In lieu of hospitalization and with approval by UNICARE, additional benefits may be allowed.
90% of network rate; subject to deductible.

80% of network rate; subject to deductible.
Lifetime benefit limit of $500,000.
100% of network rate; subject to deductible.
In lieu of hospitalization and with approval by UNICARE, additional benefits may be allowed.
80% of network rate; subject to deductible.

90% of network rate; subject to deductible.

90% of network rate; subject to the 1st Medical Network in-network deductible.

90% of network rate; subject to deductible.

80% of network rate; subject to deductible.

May require plan approved Letter of Medical Necessity.

90% of network rate; subject to deductible.
Physical, speech, cardiac and occupational therapies are limited to 40 visits per incident type per plan year.

80% of network rate; subject to deductible.
Physical, speech, cardiac and occupational therapies are limited to 40 visits per incident type per plan year.

90% of network rate; subject to deductible.
Limited to 40 visits per member per plan year.

80% of network rate; subject to deductible.
Limited to 40 visits per member per plan year.

60% of network rate; subject to deductible and balance billing.
Lifetime benefit limit of $500,000.
60% of network rate; subject to deductible and balance billing.
In lieu of hospitalization and with approval by UNICARE, additional benefits may be allowed.
60% of network rate; subject to deductible and balance billing.
90% of network rate; subject to the 1st Medical Network in-network deductible; subject to balance billing.
60% of network rate; subject to deductible and balance billing.
60% of network rate; subject to deductible and balance billing.
Physical, speech, cardiac and occupational therapies are limited to 40 visits per incident type per plan year.
60% of network rate; subject to deductible and balance billing.
Limited to 40 visits per member per plan year.

Page 11 University System of Georgia 2004 PPO and Indemnity Health Plan Options

DISEASE STATE MANAGEMENT PROGRAM

Disease State Management (DSM)
Training and Education Services
Vendor: UNICARE.
Pre-certification is required
by UNICARE.

100% of vendor negotiated rates; not subject to deductible.
To receive plan benefits coverage, participation in the appropriate DSM program is required.

100% of vendor negotiated rates; not subject to deductible.
To receive plan benefits coverage, participation in the appropriate DSM program is required.

80% of vendor negotiated rates; not subject to deductible.
To receive plan benefits coverage, participation in the appropriate DSM program is required.

Asthma, Diabetes, Oncology and Congestive Heart Failure

Not applicable.

Page 12 University System of Georgia 2004 PPO and Indemnity Health Plan Options

Indemnity Plan

Preferred Provider Option

Preferred Provider Option

Preferred Provider Option

(PPO) Plan, Georgia In-Network (PPO) Plan, National In-Network (PPO) Plan, Out-of-Network

PHARMACY PROGRAM

Generic: $10 member co-payment for up to a 30-day supply;
Preferred Brand Name: $25 member co-payment for up to a 30-day supply;
Non-Preferred Brand Name: 20% co-payment of non-preferred brand name drug cost, with minimum member co-payment of $40/maximum member co-payment of $100, for up to a 30-day supply.
The pharmacy benefits are the same for the Indemnity and the PPO/PPO Consumer Choice healthcare plans. If the usual and customary charge for a generic or preferred brand name drug is less than the co-payment amount, the member will pay the lesser of the two.
If a physician indicates "Brand Necessary" on a prescription, then only a preferred or nonpreferred brand name medication can be dispensed. The member will be responsible for the preferred/non-preferred brand name medication co-payment. If a physician does not indicate "Brand Necessary" and the member chooses a preferred/non-preferred brand name medication over its available generic equivalent, the member will be required to pay the generic co-payment. In addition to paying the generic co-payment, the member will also responsible for paying the difference in the cost between the generic and the preferred/non-preferred brand name drug. This difference in member cost is sometimes referred to as an ancillary charge.
Days Supply A member will be charged one co-payment per 30-day retail supply of a prescription drug, subject to plan design and plan coverage rules.
Maintenance Medications Maintenance medications are those prescription drugs that a member may obtain for a period of up to 90 days. The member will be charged one co-payment per 30-day supply, subject to plan design and plan coverage rules.
Other Coverage Rules For specific prescribed drugs, the plan may impose certain requirements. Those requirements may include prior medical authorization, limits on the day supply amount of the prescribed medication and/or limits on the number of approved units/tablets of medication per prescription.

Quarterly Out-of-Pocket Maximum The following quarterly out-of-pocket maximum amounts (stop loss) for members who obtain generic and preferred brand name prescription medications will apply:

Employee Employee + Child (2 covered members) Employee + Spouse (2 covered members) Family (3 or more covered members)

$450 per quarter $900 per quarter $900 per quarter $1,350 per quarter

Upon a member reaching his/her quarterly out-of-pocket maximum, his/her prescription drug co-payments will be waived for any additional generic and preferred brand name medications for the remainder of that quarter. Member co-payments will resume at the beginning of the next quarter and will be charged until the plan thresholds are reached for that quarter. A quarter will consist of three consecutive months and designated as follows:

1st quarter = January through March 2nd quarter = April through June

3rd quarter = July through September 4th quarter = October through December.

Important Notes:
Co-payments for non-preferred brand name medications will NOT apply to the quarterly out-of-pocket maximum benefit.
Prescription drug co-payments do NOT apply to University System of Georgia medical annual deductibles or to medical maximum annual out-of-pocket limits (stop loss).
If a member purchases a preferred brand name prescription drug that is not indicated as "Brand Necessary," and there is a generic alternative available; only the $10 generic member co-payment will be applied to the quarterly maximum out-of-pocket member benefit. The difference in cost between the generic alternative and the preferred brand name medication will NOT apply to the quarterly maximum out-of-pocket member benefit.

Vendor: Express Scripts.

There is no Coordination of Benefits (COB) for allowed pharmacy charges between the University System of Georgia pharmacy plan and another pharmacy/medical plan in which the member may be enrolled.

For additional information regarding the Pharmacy Benefit Manager Program, please contact Express Scripts Customer Service at 1-877-650-9341/TDD 1-800-842-5754.

BEHAVIORAL HEALTH SERVICES

Mental Health and Substance Abuse
Facility Charges

Inpatient 90% of UCR charges; subject to deductible.
Maximum benefit coverage of 60 days per person per plan year; 90 days per person per lifetime.
Pre-certification is required by UNICARE.

Inpatient In-network: 90% of network rate; subject to deductible and to a separate $100 hospital deductible. Out-of-network: 60% of network rate; subject to deductible and to a separate $100 hospital deductible. Balance billing may apply.
Maximum benefit of 60 combined mental health and substance abuse days per person per plan year.
Substance abuse coverage limited to 3 episodes per lifetime.

Not applicable.

Provider Charges

Inpatient 90% of UCR charges; subject to deductible.
Outpatient 80% of UCR charges; subject to deductible.
Maximum benefit coverage of 20 visits per person per plan year.
UNICARE may approve up to 50 visits per year under the following conditions: (1) in lieu of inpatient treatment; or (2) immediately following hospital confinement for the same condition.
Vendor: BCBSGA Prudent Buyer Program and/or BCBS National Participating Provider.

Brief-Therapy Not available. Annual Visit Limit

Partial/Day Hospitalization & Intensive Outpatient Charges 90% of network rate; subject to deductible and to a separate $100
hospital deductible. Maximum benefit of 30 combined visits/days of partial day/hospitaliza-
tion and intensive outpatient treatment per person per plan year. Benefit coverage is only available at in-network Magellan facilities.

Inpatient In-network: 80% of network rate; subject to deductible. Maximum of 60 visits per person per plan year. Out-of-network: 50% of network rate; subject to deductible and balance billing. Maximum of 25 visits per person per plan year.

Not applicable.

Benefit coverage is only available when using an in-network Magellan provider for Partial/Day Hospitalization & Intensive Outpatient Charges
Outpatient In-network: 80% of network rate with authorization from Magellan; subject to deductible. Maximum benefit coverage of 50 combined mental health,
substance abuse and brief-therapy visits per person per plan year. Out-of-network: 50% of network rate without authorization from Magellan; subject to deductible and to balance billing.

r1e-tqM8ou0rdeai0rsge-eute6dellb3rtl.mePa1cFiInnnPo-iaMe9,nnOiafl9weituta4rihPmrecf3ceedtopeO(ntuTMmvroecerDRbreea-pcaqdDgerTegrueerlsel6-ieAt,l.rciav7epfeen8Nidrllc-et,aa3oiaTwftt1fsyie9oi:lw-nl3i8itsh60)

Maximum benefit coverage of 25 combined mental health, substance

abuse and brief-therapy visits per person per plan year. Plan cover-

age/benefits limited to services/treatments rendered by a Psychiatrist

(MD) or a Psychologist (Ph.D).

100% of the network rate; not subject to deductible. Three of the 50 combined mental health and substance abuse visits
may be used for brief-therapy consultations. A Magellan network provider must pre-certify and conduct the
brief-therapy session. Annual out-of-pocket maximum of $2,500 per patient per plan year for referred network care. Annual out-of-pocket maximum applies to combined inpatient and outpatient services.

Not applicable.

Page 13 University System of Georgia 2004 PPO and Indemnity Health Plan Options

ORGAN & TRANSPLANT PROGRAM

For additional information regarding the Centers of Expertise
Program for organ and tissue transplants, please contact
UNICARE at 1-800-828-6518/ TDD 1-800-368-4424.
Prior approval is required by UNICARE.
Lifetime benefit limit of $500,000.

The UNICARE Centers of Expertise Program for organ and tissue transplants are the same for the Indemnity and PPO/PPO Consumer Choice plan options. This program is a national network of credentialed medical providers. The Centers of Expertise Program directs patients to network heart, liver, lung and bone marrow transplant specialists.
In-network: 90% of vendor network rate at a UNICARE contracted transplant center; subject to deductible and to a separate $100 hospital co-payment. Lifetime benefit limit for expenses related to the donor search for those individuals using a UNICARE contracted transplant center is $10,000.
Out-of-network: 60% of UCR at a non-contracted UNICARE transplant center; subject to deductible, to separate $100 hospital co-payment and to balance billing. There is no benefit coverage for expenses related to the donor search when using a non-contracted UNICARE transplant center.

Not applicable.

Page 14 University System of Georgia 2004 PPO and Indemnity Health Plan Options

PPO ConsumerChoice Option

The PPO Consumer Choice option was established by Georgia statute in 1999. The statute permits a PPO participant to nominate an out-of-network healthcare provider to render medical care to a covered member at the in-network level of benefit coverage. The Consumer Choice Option only applies to licensed healthcare providers within the state of Georgia.
If a nominated healthcare provider accepts a member's PPO Consumer Choice nomination and if the PPO approves the healthcare provider, the in-network relationship will exist only between the provider and the designated patient. The PPO Consumer Choice nomination will remain in effect until either the provider or the patient terminates the relationship.

If an out-of network provider declines a member's PPO Consumer Choice nomination, services from that provider will be considered as out-of-network. If a member selects the PPO Consumer Choice option during an open enrollment period, he/she will be required to continue with that healthcare plan choice for the remainder of the plan year.
The healthcare premium for a member who elects the PPO Consumer Choice Plan Option will be greater than the healthcare premium for a member who elects the standard PPO plan.

PPO SERVICE AREAS

Georgia In-Network (1st Medical Network)-- PPO/PPO Consumer Choice
The Georgia service area (1st Medical Network) includes the state of Georgia and the border community areas of Phenix City (Russell County), Alabama; Cleveland (Bradley County), Tennessee; and Chattanooga (Hamilton County), Tennessee. The zip

code area in which you receive service is used to determine whether or not you are in the Georgia service area. If you receive covered services from a 1st Medical Network provider located in one of the zip codes below, you receive the highest level of benefit coverage available in the PPO options.

Georgia

Alabama

Tennessee

All Counties

Phenix City Area Russell County

Cleveland Area Bradley County

Chattanooga Area Hamilton County

All Zip Codes

36851 36856 36858 36859 36860 36867

36868 36869 36870 36871 36875

37310 37311 37312 37320 37323 37353 37364

37302 37304 37308 37315 37341 37343 37350 37351 37363

37373 37377 37379 37384 37401 37402 37403 37404 37405

37406 37407 37408 37409 37410 37411 37412 37414 37415

37416 37419 37421 37422 37424 37450

(Please Remember: the PPO Consumer Choice Option only applies to licensed healthcare providers within the state of Georgia.)
National In-Network (Beech Street)
The service area for the National Network (Beech Street) includes all zip codes located within the United States other than those identified for the 1st Medical Network. The national network benefit level of coverage is generally 80% of the contracted rate.
If a member uses a Beech Street provider that is located within the Georgia In-Network (1st Medical Network) service area, the provider will be considered to be out-of-network.

Pre-Certification forCertain Outpatient

Procedures/Diagnostic

Tests

Plan Year 2004

Page 15 University System of Georgia 2004 PPO and Indemnity Health Plan Options

The final decision regarding the appropriate level of medical treatment for you and your family continues to be the joint responsibility of you and your physician. The Medical Utilization Management Review program, provided by UNICARE, is designed to evaluate medical alternatives. It is neither designed nor intended to practice medicine. The review
process does not replace the medical advice of your physician; the review process ensures that you are aware of all medical options before you receive care.

C ertain outpatient procedures and diagnostic tests will require pre-certification. As soon as your physician recommends an outpatient procedure for you or for a covered dependent, please ask your doctor to provide you with the CPT code for that procedure. You may then contact the UNICARE Medical Utilization Management Review program (1-800-233-5765/TDD 1-800-368-4424) or the BCBSGA customer service unit (1-800-424-8950/TDD 404-842-8073) to determine whether pre-certification is required.
If the procedure requires pre-certification, you must call the Medical Utilization Management Review program at least 48 hours prior to the scheduled procedure, unless the procedure is an emergency. Outpatient pre-certification review is not required for covered retirees/covered spouses of retirees who have Medicare Part B. The following medical CPT procedure categories require pre-certification:
CAT or CT Scans (computerized axial tomographies), except brain and spine 70480 through 70482; 70490 through 70492; 71250; 71260; 71270; 71275; 72192 through 72194; 73200 through 73202; 73700 through 73702; 74150; 74160; 74170; 76375; 76380
Colonoscopies 45378 through 45385
Endoscopies 43234; 43235; 43239
Esophageal Surgeries 43280; 43289; 43324 through 43326
Laparoscopies and/or Peritoneoscopies 49320; 49329; 58578; 58550; 58551; 58660 through 58662; 58679
MRAs (magnetic resonance angiographies) 70544 through 70549; 71555; 72159; 73225; 73725; 74185; 72198
MRIs (magnetic resonance imaging) 70336; 70540 through 70543; 70551 through 70553; 71550 through 71552; 72141; 72142; 72146 through 72149; 72156 through 72158; 72195 through 72197; 73218 through 73223; 73718 through 73723; 74181 through 74183; 75552 through 75556; 76093; 76094; 76400; 76375
Nasal Surgeries 30400 through 30520; 30620; 30930
Pet Scans 78608; 78609; 78459; 78491; 78492; 78810
Sleep Studies 95805 through 95808; 95810; 95811
Uvulopalatopharynogoplasties 42120; 42140; 42145; 42299; 42950

PPO/PPO Consumer Choice Plan Participants: Georgia Network (1st Medical Network) Providers When a member uses a Georgia Network provider, the medical provider is responsible for obtaining the required pre-certification from UNICARE for these outpatient procedures or diagnostic tests.
National Network (Beech Street) and Out-of-Network Providers When a member uses a National Network provider or an Out-of-Network provider, it is his/her responsibility to obtain the necessary pre-certification from UNICARE. The member must contact UNICARE at least 48 hours prior to his/her scheduled medical procedure, unless the procedure is an emergency.
If a member uses a National Network (Beech Street) provider, and/or an Out-of-Network provider, and he/she fails to comply with the Medical Utilization Management Review requirements, a penalty may be assessed for each respective outpatient procedure.
The member penalty for an outpatient procedure will be a percentage of the allowed amount, with a minimum penalty of $100, and a maximum penalty of $400, for each procedure. The maximum annual member penalty for outpatient procedures will be $1,000. These member penalties will not apply toward the annual deductible or toward the annual maximum out-ofpocket limits (stop loss). In addition, a member's benefit coverage may be denied for any treatment that is received, but is not deemed to be medically necessary.
Indemnity Plan Participants: Blue Cross Blue Shield of Georgia (BCBSGA) Participating Physician Program When a member uses a BCBSGA Participating Physician, the medical provider is responsible for obtaining the required pre-certification from UNICARE for these outpatient procedures or diagnostic tests.
Use of a Blue Cross Blue Shield (BCBS) National Participating Provider/ Non-Participating Physician When a member uses a BCBS National Participating Provider or a non-participating physician, it is the member's responsibility to obtain the necessary pre-certification from UNICARE for these outpatient procedures or diagnostic tests. The member must contact UNICARE at least 48 hours prior to his/her scheduled medical procedure, unless the procedure is an emergency.
If a member fails to comply with Medical Utilization Management Review requirements, a $200 member penalty may be assessed. This member penalty will not apply toward the annual deductible or toward the annual maximum out-of-pocket limits (stop loss). In addition, a member's benefit coverage may be denied for any treatment that he/she receives that is not deemed to be medically necessary.

For More Information
For more information, please contact your Human Resources/Payroll Department.

PPO and Indemnity Option Members
MEDCALL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-785-0006

For emergency room referral and for medical

TDD 1-800-368-4424

information from a registered nurse 24-hours

a day, seven days a week.

Pharmacy Benefits Manager
(Express Scripts, Inc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-877-650-9341

For information regarding your pharmacy benefit

TDD 1-800-842-5754

plan and covered benefits, 24-hours a day, seven

days a week. The 2004 Express Scripts/University

System of Georgia Preferred Drug List will be available
on-line at: . . . . . . . . . www.usg.edu/admin/humres/benefits/health/

(effective 10-01-03).

Pre-Certification for Specific Out-Patient/ All In-Patient Hospital Services
For information, call UNICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-233-5765
TDD 1-800-368-4424

Blue Cross Blue Shield of
Georgia Customer Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-424-8950

For information regarding eligibility and claims processing

TDD 404-842-8073

PPO Option
For information regarding the availability and
status of pending network provider(s) within the
state of Georgia, please call 1st Medical Network . . . . . . . . . . . . . 1-800-675-6492

For information regarding the network of National PPO providers (Beech Street), please call
Blue Cross Blue Shield of Georgia Customer Service . . . . . . . . . 1-800-424-8950
TDD 404-842-8073 For information regarding the network of behavioral
health service providers, please call Magellan . . . . . . . . . . . . . . . 1-800-631-9943
TDD 678-319-3860

The University System of Georgia will link vendor information to its Web site. Please go to the following site for online information:
www.usg.edu/admin/humres/benefits/health/

PPO Provider Directories For on-line information regarding the networks of Georgia PPO providers (1st Medical Network) and
the National PPO providers (Beech Street) . . . . . . www.healthygeorgia.com
Your campus Human Resources/Payroll Departments will have access to both of these on-line directories.
For PPO Choice Option Members -- Only medical Providers with a valid Georgia license may be nominated under the Consumer Choice Option Statute.
For information regarding the availability and status of
pending network providers, please call 1st Medical Network . .1-800-675-6492
For nomination of Behavior Health Services provider(s),
please call Magellan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-631-9943
TDD 678-319-3860 For nomination of Transplant Network Provider(s),
please call UNICARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-828-6518
TDD 1-800-368-4424
Indemnity Option
For information regarding the providers in the Blue Cross Blue Shield of Georgia (BCBSGA) Participating Physician Program, please call Blue Cross Blue Shield of Georgia Customer Service at 1-800-424-8950/TDD 404-842-8073.
For information regarding the indemnity providers in the Blue Cross Blue Shield (BCBS) National Participating Provider Network, please call Blue Cross Blue Shield Customer Service at 1-800-810-BLUE (2583).
Indemnity Provider Directories For online information regarding the Georgia Participating Physician Program and the National Participating Provider Network, please go to: www.usg.edu/admin/humres/benefits/health/. Your campus Human Resources/Payroll Department will have access to both of these online directories.

"Creating a More Educated Georgia"

Board of Regents of the University System of Georgia 270 Washington Street Atlanta, Georgia 30334
2003 Board of Regents. 9/03.