In-Network Benefit Level Out-of-Network Benefit Level
Deductibles, Maximums, Etc.
Deductible: one deductible for employee,
One for spouse, one for all children
Combined
-Individual $0 $300
-Family $0 $900
Coinsurance: the percentage of eligible Plan pays 100% Plan pays 60%
Charges for which you are responsible
Out-of-pocket Calendar Year Maximum
-Individual (excludes deductible) N/A $2,000
-Family (excludes deductible) N/A $6,000
Lifetime Maximum Unlimited $2,000,000
Preventive Health Care
Well-child care, immunizations $15 copayment Plan pays 60%; annual
Deductible waived for
Well child care through
Age 5
Periodic health examinations $15 copayment Not covered
Annual gynecology examination $20 copayment Plan pays 60% after deductible
(No PCP referral required- Must use for annual Pap and
network provider for in-network benefits) mammogram
Prostate screening $15 copayment Plan pays 60% after deductible for annual exam
Primary care physician (PCP) office visit $15 copayment Plan pays 60% after deductible
(includes lab, radiology and office surgery)
Primary care physician after hours office $20 copayment Plan pays 60% after deductible
Visit
Specialty care physician office visits $20 copayment Plan pays 60% after deductible
(PCP referral required)
Second surgical opinion $20 copayment Plan pays 60% after deductible
(PCP referral required)
Allergy care (Primary care physician $15 PCP copayment Plan pays 60% after deductible
Office visit, specialty care, allergy shots $20 specialist copayment
Serum and testing)
Maternity services (prenatal/delivery/ all physician charges Plan pays 60% after deductible
Postpartum) related to prenatal,
Delivery and postpartum
Care are covered by $20
Copayment at first office visit
Vision care services provided by a $20 copayment Plan pays 60% after deductible
Network ophthalmologist or
Optometrist for treatment of acute
Conditions (No PCP referral required)
Services provided by network $20 copayment Plan pays 60% after deductible
Dermatologists (NO PCP referral required)
Daily room, board and general nursing Plan pays 100% Plan pays 60% after deductible
Care at semi-private room rate; ICU/CCU
Charges; other medically necessary
Hospital charges such as diagnostic x-ray
And lab services; newborn nursery care
Physician services (surgery, anesthesia, Plan pays 100% Plan pays 60% after deductible
Radiology, pathology, etc.)
Facility/hospital charges (including Plan pays 100% Plan pays 60% after deductible
Diagnostic x-ray and lab services)
Outpatient surgery outside physician’s $100 copayment Plan pays 60% after deductible
Office (facility component only)
Physician services (surgery, anesthesia, Plan pays 100% Plan pays 60% after deductible
Radiology, pathology, etc.)
Therapy services: Annual visit limits are combined between in-network and
Out-of-network
-Speech therapy $20 copayment; 20 visit Plan pays 60% after deductible
calendar year maximum 20-visit calendar year maximum
-Physical, occupational therapy $20 copayment; 20-visit Plan pays 60% after deductible
calendar year maximum 20-visit calendar year maximum
(includes Chiropractic care)
-Respiratory therapy Plan pays 100%; 40-visit Plan pays 60% after deductible
calendar year maximum 40-visit calendar year maximum
-Radiation therapy, chemotherapy Plan pays 100% Plan pays 60% after deductible
Life-threatening illness, serious accidental $100 copayment, waived $100 copayment, waived if
Injury or with a PCP referral if admitted admitted
Non-emergency use of the emergency Not covered Not covered
Room
Mental Health/Substance Abuse No Primary Care Physician referral required. Services must
Services (Provided through authorized by Magellan Behavioral Health at 1-800-292-2879
Magellan Behavioral Health)
Inpatient (facility and physician fee) Plan pays 100%; 30-day Not covered
Calendar year maximum
Outpatient $25 copayment, 20-visit Not covered
Calendar year maximum
Inpatient alcohol or substance Plan pays 100%; 6-day Not covered
Abuse detoxification calendar year maximum
(combined with other inpatient
mental health and substance
abuse benefits)
Other Services Annual maximum is combined between in-network and
Out-of-network
Skilled nursing facility Plan pays 100%; 30-day Plan pays 60% after deductible
Calendar year maximum 30-day calendar year maximum
Home health care Plan pays 100%; 120-visit Plan pays 60% after deductible
Calendar year maximum 120-visit calendar year maximum
Hospice care Plan pays 100%; $10,000 Plan pays 100%; $10,000
Lifetime maximum lifetime maximum
Ambulance Plan pays 100% when Plan pays 100% when
Medically necessary medically necessary
Prescription Drugs Prescriptions must be written by a network physician or an
Emergency room physician
Participating pharmacies include: $10 copayment for generic Plan pays 60% after deductible
Bi-Lo, CVS, Drug Emporium, Eckerd, (up to 30-day supply)
Kmart, Kroger, Publix, Walgreens, $20 copayment for name Plan pays 60% after deductible
Wal-Mart, Winn-Dixie, and many brands (up to 30-day supply)
Independent pharmacies
Mail order maintenance drugs $40 copayment (up to Mail order prescriptions not
90-day supply-maintenance available out-of-network
medications only)
100% coverage for Preventive & Diagnostic services, two visits per year. No
deductible.
80% coverage after a $50 deductible for restorative services, ie. Fillings, repair
work to existing bridges, crowns, inlays, etc.
50% coverage after the same $50 deductible for replacement services, ie.
Bridges, crowns, inlays, etc.
$10,000 of Life Insurance and Accidental Death and Dismemberment on all
employees
$2,500 of Life Insurance on covered spouses
$1,000 of Life Insurance on covered children
Group medical, prescription card and dental coverage are effective on the 91st day from
Date of hire.
Any questions about coverage can be directed to Marla Coggins in the Human Resource
Department at 770-387-5020, Carter Shaw or Jean McDaniel at the Shaw Agency.
All claims can be directed to Carter Shaw or Jean McDaniel at:
The Shaw Agency
201 West Main Street
Cartersville, Ga. 30120
770-382-0951
770-382-0853 Fax
EMERGENCY DATA SHEET
NAME____________________________________DEPARTMENT________________
SSN#______________________________DATE OF BIRTH_____________________
STREET______________________________________________________________
CITY______________________________STATE____________ZIP_______________
PHONE #___________________________RACE____________SEX______________
DRIVER’S LICENSE#____________________________________________________
CIRCLE ONE: FULL TIME EMPLOYEE OR PART TIME EMPLOYEE
SEASONAL EMPLOYEE OR OTHER______________________
SPOUSES’S INFORMATION
NAME_________________________________SSN#___________________________
DATE OF BIRTH_________________________
CHILDREN INFORMATION
NAME (S) DATE OF BIRTH SSN# SEX
1.
2.
3.
4.
5.
PERSON TO CONTACT IN CASE OF AN EMERGENCY
NAME________________________________RELATIONSHIP___________________
ADDRESS_____________________________________________________________
City state zip
HOME PHONE #_______________________WORK PHONE #___________________
SECOND CHOICE
NAME________________________________RELATIONSHIP___________________
ADDRESS_____________________________________________________________
City state zip
HOME PHONE #_______________________WORK PHONE#___________________