Medical & Prescriptions
Which Plan Is Right For Me?
Evaluate your prior health care usage and select the plans that fit your lifestyle and needs. Consider this:
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- Do you take regular prescription medications?
- Are you anticipating surgery or non-preventive dental care?
- Did you experience a Qualified Life Event this year?
- Do your current plans provide the coverage you need?
A little bit of planning will help you choose the best coverage for your unique situation.
Medical Plan Comparison
PT Solutions offers three health plan options through Anthem/Blue Cross Blue Shield of Georgia (Anthem/BCBS): the Premium Plan, Plus Plan and the Value Plan which is a High Deductible Health Plan and includes a Health Savings Account (HSA). All three plans include prescription drug coverage.
Premium Plan —
Higher premiums than the Value or Plus Plan, but lower deductibles and out-of-pocket maximums.
Plus Plan —
Lower premiums and a higher deductible than the Premium Plan with 10% vs. zero percent coinsurance.
Value Plan with HSA —
Lowest premiums, plus:
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- You pay the full cost of services, including prescription drugs, until you meet the deductible.
- Preventive care is fully covered even if you have not reached your plan deductible.
- You can make pre-tax contributions to an HSA through payroll deductions to pay for out-of-pocket health care expenses and build savings.
While you can see any provider you choose, maximize your benefits and reduce your out-of-pocket expenses by using an in-network provider. For care received out of network, the provider may bill you for amounts exceeding the negotiated discounted rate.
To find an in-network provider:
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- Go to bcbsga.com and select FIND CARE.
- Under “Search as a Guest,” click on CONTINUE and follow prompts
- GEORGIA: Click on Blue Open Access POS (Select Network) as your network
- OUTSIDE GEORGIA: Click on National PPO (BlueCard PPO) as your network
Call (855) 397-9267 if you need assistance.
| Medical Plan Highlights | Anthem/BCBS Premium Plan | Anthem/BCBS Plus Plan | Anthem/BCBS Value Plan with Health Savings Account (HSA) |
|---|---|---|---|
| Deductible (calendar year) | In-Network* | In-Network* | In-Network* |
| Individual | $1,000 | $1,500 | $3,000 |
| Family | $3,000 | $4,500 | $6,000 |
| Coinsurance | 0% | 10% | 20% |
| Out of Pocket Maximum | Includes Ded and Copays | ||
| Individual | $4,000 | $6,000 | $7,000 |
| Family | $8,000 | $12,000 | $14,000 |
| Lifetime Maximum | Unlimited | Unlimited | Unlimited |
| Office Visits | |||
| Preventive Care Visit | Member pays 0% | Member pays 0% | Member pays 0% |
| Primary Care Physician | $25 copay | $35 copay | 20% after ded |
| Specialist/Other Specialists | $50 copay | $50 copay | 20% after ded |
| Urgent Care | $50 copay | $50 copay | 20% after ded |
| Therapy Visits (combined - PT and OT) | $50 copay; 80 visits max | $50 copay; 80 visits max | 20% after ded; 80 visits max |
| Telehealth - LiveHealth Online | 12 free visits then $25 copay | 12 free visits then $35 copay | 0% after ded |
| Acupuncture | $50 copay | $50 copay | 20% after ded |
| Lab Services | |||
| Processed in office | Included in Office Visit Copay | Included in Office Visit Copay | 20% after ded |
| Processed out of office | 0% after ded | 10% after ded | 20% after ded |
| Hospital Services | |||
| Inpatient | 0% after ded | 10% after ded | 20% after ded |
| Outpatient | 0% after ded | 10% after ded | 20% after ded |
| Emergency Room Treatment | $500 copay, no ded | $500 copay, then 10% | 20% after ded |
| Prescription Drugs** | |||
| Retail (30 day supply) | |||
| Tier 1 | $15 | $15 | 20% after ded |
| Tier 2 | $45 | $35 | 20% after ded |
| Tier 3 | $85 | $60 | 20% after ded |
| Tier 4 | 20% coinsurance up to $250 max per script | 20% coinsurance up to $300 max per script | 20% after ded |
| Mail Order (90 day supply) | $38 / $113 / $213 / 20% coinsurance up to $250 | $15 / $70 / $180 / 20% coinsurance up to $300 | 20% after ded |
| *For out-of-network benefits, please see the plan benefit summaries. ** Generally, Tier 1 = Generic, Tier 2 = Brand Preferred, Tier 3 = Brand Non-Preferred, Tier 4 = Specialty |
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| Note: Please consult plan documents for full benefits, exclusions, and limitations. | |||
Certain medications are considered preventive and will be covered at 100% (no cost to you) regardless of what plan you are enrolled. For those enrolled in the Value HSA plan medications that fall under the preventive list will not apply to the deductible. For a list of ACA preventive medications, please reference the above Anthem document titled ACA Preventive Care Drug List.
IRS Releases Notices on Expenses Treated as Amounts Paid for Medical Care and Preventive Care for Purposes of Qualifying as an HDHP Under Section 223
On October 17, 2024, the Internal Revenue Service (IRS) released Notice 2024-71 (Expenses Treated as Amounts Paid for Medical Care) and Notice 2024-75 (Preventive Care for Purposes of Qualifying as a High Deductible Health Plan (HDHP) under Section 223).
Notice 2024-71 provides a safe harbor under Section 213 of the Internal Revenue Code (Code) for amounts paid for condoms.
Notice 2024-75 expands the list of preventive care benefits permitted to be provided by an HDHP under Section 223(c)(2)(C) of the Code without a deductible, or with a deductible below the applicable minimum deductible for the HDHP, to include over-the-counter oral contraceptives (including emergency contraceptives) and male condoms. The Notice also clarifies that: 1) all types of breast cancer screening for individuals who have not been diagnosed with breast cancer are treated as preventive care under Section 223(C)(2)(C); 2) continuous glucose monitors for individuals diagnosed with diabetes are generally treated as preventive care under Section 223(c)(2)(C); and 3) the new safe harbor for absence of a deductible for certain insulin products in Section 223(c)(2)(G) applies without regard to whether the insulin product is prescribed to treat an individual diagnosed with diabetes or prescribed for the purpose of preventing the exacerbation of diabetes or the development of a secondary condition.
