This plan has access to the BCBS Nationwide network which utilizes most of the major
hospitals, pharmacies and many doctors as network providers. There is no out-of-network
coverage with this plan. Effective July 1, 2011 there is an unlimited lifetime medical
maximum. The co-payment for a primary care physician office visit is $25.00; specialist
is $50.00. There is also a deductible for non-copayment services of $400.00 for employee
only coverage, $800.00 employee plus one dependent, and $1,200.00 for 3 or more family
members. You may self-refer to a specialist on the provider listing. Hospital co-payment
is $100.00 per day with a maximum of 3 days co-payment. See prescription drug information
below. More information, including a list of Blue Cross providers is available on
Group Benefits website: www.groupbenefits.org or https://www.bcbsla.com/ogb
Administered by Express Scripts, Inc. (ESI) | Member Drug Questions – 1-866-781-7533Blue Cross and Blue Shield of Louisiana works with Express Scripts, Inc. (ESI) to
administer ourprescription drug program. For ESI’s list of generic, preferred brand, non-preferred
brand, specialty andmaintenance/preventive drugs, go to www.bcbsla.com/ogb.
ESI has a robust pharmacy network that consists of a large group of conveniently located
participatingretail pharmacies as well as an optional mail-service program. You may use any pharmacy
you wish, butthere are advantages to selecting a participating network pharmacy:• Lower costs• No claims to file• No waiting for reimbursement
