Network coverage for this plan is available only in Baton Rouge, New Orleans, and
Shreveport. Members must choose between the Blue Connect and Community Blue networks.
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
