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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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Open Access POS Plans

PW_G313469

Rx Option KE Plans - Benefit Summaries (effective 1/1/2018)

Fully Insured Groups 
OAP5 500 0 KE 
OAP5 500 0 7.15K KE 
OAP5 500 10 4.4K KE 
OAP5 500 10 KE 
OAP5 500 20 2K KE 
OAP5 500 20 4.4K KE 
OAP5 500 20 KE 
OAP5 1K 0 KE 
OAP5 1K 0 7.15K KE 
OAP5 1K 10 4K KE 
OAP5 1K 20 4K KE 
OAP5 1.5K 0 KE 
OAP5 1.5K 0 7.15K KE 
OAP5 1.5K 10 KE 
OAP5 1.5K 10 7.15K KE 
OAP5 1.5K 20 7.15K KE 
OAP5 1.5K 20 KE 
OAP5 2K 0 7.15K KE 
OAP5 2K 0 KE 
OAP5 2.5K 0 KE 
OAP5 2.5K 0 7.15K KE 
OAP5 2.5K 20 KE 
OAP5 3K 20 7.15K KE 
OAP5 3.5K 0 KE 
OAP5 3.5K 0 7.15K KE 
OAP5 3.5K 20 KE 
OAP5 3.5K 30 KE 
OAP5 5K 0 KE 
OAP5 5K 0 7.15K KE 
OAP5 5K 30 KE 
OAP5 5K 20 7.15K KE 
OAP5 6K 20 7.15K KE 
OAP5 6.35K 0 KE 
OAP9 2.5K 20 KE 
OAP9 3.5K 20 KE 
OAP9 5K 20 KE 
OAP9 6.35K 0 KE 
 
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.