Transcription
BluePreferredYour Health Benefits
www.carefirst.comC ON NE CT WITH U S:CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which areindependent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.CUT7094-1S (6/17)
WelcomeWelcome to your plan for healthy livingFrom preventive services to maintain your health, to ourextensive network of providers and resources, CareFirstBlueCross BlueShield and CareFirst BlueChoice, Inc.(collectively, CareFirst) are there when you need care. We willwork together to help you get well, stay well and achieve anywellness goals you have in mind.We know that health insurance is one of the most importantdecisions you make for you and your family—and we thank you forchoosing CareFirst. This guide will help you understand your planbenefits and all the services available to you as a CareFirst member.Please keep and refer to this guide while you are enrolled in this plan.How your plan worksFind out how your health plan works and how you can access thehighest level of coverage.Managing your health carebudget just got easierWith CareFirst’s Treatment CostEstimator, you can: Quickly estimate your totalcosts Avoid surprises and savemoney Plan ahead to controlexpenses Make the best caredecisions for youVisit carefirst.com to learn more!What’s coveredSee how your benefits are paid, including any deductibles,copayments or coinsurance amounts that may apply to your plan.Getting the most out of your planTake advantage of the added features you have as aCareFirst member: Wellness discount program offering discounts on fitness gear,gym memberships, healthy eating options and more. Online access to quickly find a doctor or search for benefitsand claims. Health information on our website includes health calculators,tracking tools and podcast videos on specific health topics. Vitality magazine with healthy recipes, preventive health caretips and a variety of articles.CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Crossand Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.SUM1816-1P (8/17)
How your plan works
BluePreferred PPOSee any providerWith BluePreferred PPO, you have the freedom to visit any provider you choose. We also offeronline tools and resources at carefirst.com that give you the flexibility to manage your healthcare and wellness goals wherever you are.Benefits at a glancePreventive care and sick office visits ou are covered for all preventive care asYwell as sick office visits.Large provider network ou can choose any doctor from ourYlarge network of providers. Our networkalso includes specialists, hospitals andpharmacies—giving you many options foryour health care.Specialist servicesTake advantage of your benefits 0 cost for comprehensive preventive healthcare visits. Choose any provider you want—no referralsrequired. A network of over 43,000 CareFirstPreferred Provider Organization (PPO)providers—primary care providers (PCP),nurse practitioners, specialists, hospitals,pharmacies, urgent care centers,convenience care clinics and diagnosticcenters—in Maryland, Washington, D.C. andNorthern Virginia. If you need care outside CareFirst BlueCrossBlueShield’s (CareFirst) service area of Maryland,Washington, D.C. and Northern Virginia, youhave access to thousands of providers in all50 states and receive in-network benefits whenyou see a BlueCard PPO provider. our coverage includes services fromYspecialists without a referral. Specialistsare doctors or nurses who are highlytrained to treat certain conditions, suchas cardiologists or dermatologists.Prescription drug coverageYour plan covers prescription drugs.Hospital services ou’re covered for overnight hospitalYstays. You are also covered for outpatientservices, those procedures you get inthe hospital without spending the night.Your PCP or specialist must provide priorauthorization for all inpatient hospitalservices and may need to provide priorauthorization for some outpatient hospitalservices such as rehabilitative services,chemotherapy and infusion services.Labs, X-rays or specialty imaging overed services include providerCordered lab tests, X-rays and otherspecialty imaging tests (MRI, CT scan,PET scan, etc.).
BluePreferred PPOWell-child visitsGetting started with your planAll well-child visits and immunizationsare covered.No matter which health plan you have, one of thefirst things you should do is choose an in-networkprimary care provider or PCP. By visiting your PCPfor routine visits as recommended, he/she will getto know you, your medical history and your habits.Having a PCP who is familiar with your health canmake it easier and faster to get the care you need.In addition, when you choose a PCP, you are onestep closer to earning a financial reward!Maternity and pregnancy care ou are covered for doctor visits beforeYand after your baby is born, includinghospital stays. If needed, we also coverhome visits after the baby’s birth.Mental health andsubstance use disorderWith access to nearly 92 percent of all physiciansin the United States, your doctor is likely in thenetwork. To find regional and national providers,visit our Find a Provider tool (carefirst.com/doctor)and search by the CareFirst BlueCross BlueShieldor CareFirst BlueChoice, Inc. (CareFirst) plan or byyour doctor’s name. our coverage includes behavioral healthYtreatment, such as psychotherapy andcounseling, mental and behavioral healthinpatient services and substance usedisorder treatment.How your plan worksCareFirst BlueCross BlueShield (CareFirst) has theregion’s largest network of doctors, pharmacies,hospitals and other health care providers thataccept our health plans. Because networks varyamong CareFirst health plans, make sure you’refamiliar with your specific plan’s network.Your benefitsStep 1: Meet your deductible (if applicable)If your plan requires you to meet a deductible, youwill be responsible for the cost of your medical careup to the amount of your deductible. However, thisdeductible does not apply to all services.In-network doctors and health care providersare those that are part of your plan’s network(also known as participating providers). Whenyou choose an in-network provider, you’ll pay thelowest out-of-pocket costs.Examples of in-network services not subjectto deductible*:Out-of-network providers and doctors have notcontracted with CareFirst. If you choose to receivecare from an out-of-network provider, you canexpect to pay more and, in some cases, may beresponsible for the entire amount billed. Adult preventive visits with PCP Well-child care and immunizations with PCP OB/GYN visits and pap tests Mammograms Prostate and colorectal screenings Routine prenatal maternity servicesBluePreferred PPO gives you flexibilityand choices when you need care.CareFirst PreferredProvider Organization(PPO) networkorBlueCard PPO Network(outside of MD, DC, andNorthern VA)}Non-participating providers}In Network you pay: Visit any CareFirst PPO network provider or whenreceiving care outside MD, DC, and Northern VA, visitany BlueCard PPO provider. No referrals necessary.Out-of-network you pay: Visit a non-participating providerNo referral required. Balance billing may apply* This is not a complete list of all services. For a comprehensive explanation of your coverage, please check your Evidence of Coverage.
BluePreferred PPOStep 2: Your plan will start to pay for servicesYour full benefits will become available onceyour deductible is met. However, the level ofthose benefits will depend on whether you seein-network or out-of-network providers. Dependingon your particular plan, you may also have to pay acopay or coinsurance when you receive care.You will have different deductible amounts forin network versus out of network services. Forexample, when you see in-network providers, yourexpenses will only count toward your in-networkdeductible and out-of-network expenses willonly apply to your out-of-network deductible.Deductible requirements vary based on yourcoverage level (e.g. individual, family) therefore ifmore than one person is covered under your plan,please refer to your certificate of coverage fordetailed deductible information.In general, nonparticipating providers don’t havean agreement with CareFirst to accept the allowedbenefit as payment in full for their services. Thismeans the provider could bill you based on theactual charge for the service and you would beresponsible for paying the balance between whatwe allow for the benefit and the actual charge.Remember, you may be required to pay anonparticipating provider’s total charges at the timeof service and submit a claim for reimbursement.Out-of-pocket maximumShould you reach your out-of-pocket maximum,CareFirst will then pay 100 percent of the allowedbenefit for all covered services for the remainderof the benefit period. Any amount you pay towardyour deductible, copays and/or coinsurance willcount toward your out-of-pocket maximum.You will have a different out of-pocket maximumfor in-network and out-of-network benefits. Onceyour out-of-pocket maximum is satisfied, copays orcoinsurance amounts will not be required.Please keep in mind that out-of-pocketrequirements also differ if your coverage is eitheran individual or family plan. Detailed informationon out-of-pocket maximum amounts can be foundin your Certificate of Coverage.Out-of-area coverageYou have the freedom to take your health carebenefits with you—across the country and aroundthe world. BlueCard PPO, a program from theBlue Cross and Blue Shield Association, allowsyou to receive the same health care benefitswhile traveling outside of the CareFirst servicearea (Maryland, Washington, D.C. and NorthernVirginia). The BlueCard program includes morethan 6,100 hospitals and 600,000 other health careproviders nationally.Outside the United States, when you have BlueCross Blue Shield Global Core, you have accessto doctors and hospitals in nearly 200 countriesand territories. For more information, visitbcbsglobalcore.com.Important termsALLOWED BENEFIT: The maximum amountCareFirst approves for a covered service,regardless of what the doctor actually charges.Providers who participate in the PPO networkcannot charge our members more than theallowed amount for any covered service.COINSURANCE: The percentage of the allowedbenefit you pay after you meet your deductible.COPAY: A fixed-dollar amount you pay whenyou visit a doctor or other provider.DEDUCTIBLE: The amount of money you mustpay each year before your plan begins to pay itsportion for the cost of care.IN-NETWORK: Doctors, hospitals, labs andother providers or facilities that are part of theCareFirst’s regional and national PPO network.OUT-OF-NETWORK: Doctors, hospitals, labsand other providers or facilities that do notparticipate in CareFirst’s regional and nationalPPO network.BluePreferred PPO is underwritten by Group Hospitalization and Medical Services, Inc. or CareFirst of Maryland, Inc.CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Crossand Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.FOL5076-1P (8/17) 51
BlueVisionA plan for healthy eyes, healthy livesProfessional vision services including routine eye examinations, eyeglasses and contactlenses offered by CareFirst BlueCross BlueShield and CareFirst BlueChoice, through theDavis Vision, Inc. national network of providers.How the plan worksHow do I find a provider?To find a provider, go to carefirst.com and utilize the Find aProvider feature or call Davis Vision at 800-783-5602 for a list ofnetwork providers closest to you. Be sure to ask your provider ifhe or she participates with the Davis Vision network before youreceive care.How do I receive care from a network provider?Simply call your provider and schedule an appointment.Identify yourself as a CareFirst BlueCross BlueShield orCareFirst BlueChoice member and provide the doctor with youridentification number, as well as your date of birth. Then go to theprovider to receive your service. There are no claim forms to file.What if I go out-of-network?BlueVision offers an allowance for a routine eye exam, eyeglasses,and contact lenses at a non-Davis Vision provider. You will beresponsible for paying the entire amount of the service fees upfront. Out-of-network benefits are limited to an allowed benefit.After the services, you can submit your claim to Davis Visionfor reimbursement. You can find the claim form by going tocarefirst.com, locate For Members, then click on Forms, Vision,Davis Vision.Can I get contacts and eyeglasses in the samebenefit period?With BlueVision, the benefit covers one pair of eyeglasses or asupply of contact lenses per benefit period at a discounted price1.Mail order replacement contact lensesDavisVisionContacts.com offers members the flexibility to shopfor replacement contact lenses online after benefits are spent.This website offers a wide array of contact lenses, easy, convenientpurchasing online and quick shipping direct to your door.1As of 4/1/14, some providers in Maryland and Virginia may no longer provide these discounts.BRC6422-1P (9/17) 12 month/ 10 copay BlueVision Option 3Need more information?Visit carefirst.com or call800-783-5602.
BlueVisionSummary of BenefitsIn-Network(12-month benefit period)You PayOut-of-NetworkYou PayRoutine Eye Examinationwith dilation (per benefitperiod)Plan pays 33, you pay balance 10EYE EXAMINATIONSRoutine Eye Examination withdilation (per benefit period)FRAMES1Priced up to 70 retail 40Priced above 70 retail 40, plus 90% of the amountover 70SPECTACLE LENSES1Single Vision 35Bifocal 55Trifocal 65Lenticular 110LENS OPTIONS1,2 (add to spectacle lens prices above)Standard Progressive Lenses 75Premium Progressive Lenses(Varilux , etc.)Ultra Progressive Lenses(digital)Polarized Lenses 125 140High Index Lenses 55Glass Lenses 18Polycarbonate Lenses 30Blended invisible bifocals 20Intermediate Vision Lenses 30Photochromic Lenses 35Scratch-Resistant Coating 20Standard Anti-Reflective (AR)Coating 45Ultraviolet (UV) Coating 15Solid Tint 10Gradient Tint 12Plastic Photosensitive Lenses 65 751CareFirst BlueChoice does not underwrite lenses, frames and contactlenses in this program. This portion of the Plan is not an insuranceproduct. As of 4/1/14, some providers in Maryland and Virginia mayno longer provide these discounts.2 pecial lens designs, materials, powers and frames may requireSadditional cost.3 Some providers have flat fees that are equivalent to these discounts.ExclusionsThe following services are excluded from coverage:1. Diagnostic services, except as listed in What’s Covered under the Evidenceof Coverage.2. Medical care or surgery. Covered services related to medical conditions ofthe eye may be covered under the Evidence of Coverage.3. Prescription drugs obtained and self-administered by the Member foroutpatient use unless the prescription drug is specifically covered under theEvidence of Coverage or a rider or endorsement purchased by your Groupand attached to the Evidence of Coverage.4. Services or supplies not specifically approved by the Vision Care Designeewhere required in What’s Covered under the Evidence of Coverage.5. Orthoptics, vision training and low vision aids.6. Glasses, sunglasses or contact lenses.7. Vision Care services for cosmetic use.Exclusions apply to the Routine Eye Examination portion of your visioncoverage. Discounts on materials such as glasses and contacts may still apply.Benefits issued under policy form numbers: MD/CF/VISION (R. 10/11) DC/CF/VISION (R. 1/06) VA/CF/VISION (R. 1/06) CFMI/Vision Rider (10/11) MD/BCOO/VISION (R. 10/11) DC/BCOO/VISION (R. 1/06) VA/BCOO/VISION(R. 1/06) and any amendments.CONTACT LENSES1Contact Lens Evaluation andFitting85% of retail priceConventional80% of retail priceDisposable/PlannedReplacement90% of retail priceDavisVisionContacts.comMail Order Contact LensReplacement OnlineDiscounted pricesLASER VISION CORRECTION1Up to 25% off allowed amount or 5% off anyadvertised special3CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Crossand Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.BRC6422-1P (9/17) 12 month/ 10 copay BlueVision Option 3
Patient-Centered Medical HomeSupporting the relationship between you and your doctorWhether you’re trying to get healthy or stay healthy, you need the bestcare. That’s why CareFirst1 created the Patient-Centered Medical Home(PCMH) program to focus on the relationship between you and yourprimary care provider (PCP).The program is designed to provide your PCP with a more completeview of your health needs. Your PCP will be able to use informationto better manage and coordinate your care with all your health careproviders including specialists, labs, pharmacies and others to ensureyou get access to, and receive the most appropriate care in the mostaffordable settings.Extra care for certain health conditionsIf you have certain health conditions, your PCMH PCP will partnerwith a care coordinator, a registered nurse, to: Create a care plan based on your health needs with specificfollow up activities Review your medications and possible drug interactions Check in with you to make sure you’re following yourtreatment plan Assist you in obtaining services and equipment necessary tomanage your health condition(s)A PCP is important toyour healthBy visiting your PCP for routinevisits, you build a relationship,and your PCP will get to knowyou and your medical history.If you have an urgent healthissue, having a PCP who knowsyour history often makes iteasier and faster to get the careyou need.Even if you are young andhealthy, or don’t visit the doctoroften, choosing a PCP is key tomaintaining good health.PCPs play a huge role in keeping you healthy for the long run. If you don’t already have arelationship with a doctor, you can begin researching one today! 1To find a PCMH PCP,look for the PCMH logowhen searching forprimary care providersin our Provider Directoryor log in to My Accountand click Select/ChangePCP under Quick Links.All references to CareFirst refer to CareFirst BlueCross BlueShield and CareFirst, BlueChoice, Inc., collectively.CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Crossand Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.CST1310-1P (9/17)
What’s covered
BluePreferred Summary of BenefitsSmithsonian InstitutionServicesIn-Network You Pay1,2Out-of-Network You Pay1,3Visit www.carefirst.com/doctor to locate providersFIRSTHELP—24/7 NURSE ADVICE LINEFree advice from a registered nurse.Visit www.carefirst.com/needcare to learnmore about your options for care.When your doctor is not available, call FirstHelp at 800-535-9700 to speak with aregistered nurse about your health questions and treatment options.BLUE REWARDSVisit www.carefirst.com/bluerewards formore informationBlue Rewards is an incentive program where you can earn up to 600 for taking anactive role in getting healthy and staying healthy.ANNUAL DEDUCTIBLE (Benefit period)4Individual 250 500Family 500 1,000ANNUAL OUT-OF-POCKET MAXIMUM (Benefit period)5Medical6 1,500 Individual/ 3,000 Family 3,000 Individual/ 6,000 FamilyPrescription Drug6 4,500 Individual/ 9,000 FamilyAll drug costs are subject to in-networkout-of-pocket maximumNoneNoneWell-Child Care (including exams &immunizations)No charge*CareFirst pays 100% of Allowed BenefitAdult Physical Examination(including routine GYN visit)No charge*Deductible, then 30% of Allowed BenefitBreast Cancer ScreeningNo charge*30% of Allowed BenefitPap TestNo charge*30% of Allowed BenefitProstate Cancer ScreeningNo charge*Deductible, then 30% of Allowed BenefitColorectal Cancer ScreeningNo charge*Deductible, then 30% of Allowed BenefitOffice Visits for Illness 20 per visitDeductible, then 30% of Allowed BenefitImaging (MRA/MRS, MRI, PET & CAT scans)Deductible, then 10% of Allowed BenefitDeductible, then 30% of Allowed BenefitLabDeductible, then 10% of Allowed BenefitDeductible, then 30% of Allowed BenefitX-rayDeductible, then 10% of Allowed BenefitDeductible, then 30% of Allowed BenefitAllergy TestingDeductible, then 10% of Allowed BenefitDeductible, then 30% of Allowed BenefitAllergy Shots 5 per visitDeductible, then 30% of Allowed BenefitPhysical, Speech and Occupational Therapy(limited to 30 visits/condition/benefitperiod) 20 per visitDeductible, then 30% of Allowed BenefitChiropractic (limited to 20 visits/benefitperiod) 20 per visitDeductible, then 30% of Allowed BenefitAcupunctureNot covered (except when approved orauthorized by Plan for Anesthesia).Not covered (except when approved orauthorized by Plan for Anesthesia).Urgent Care Center 20 per visit 20 per visitEmergency Room—Facility Services 100 per visit (waived if admitted) 100 per visit (waived if admitted)Emergency Room—Physician ServicesNo charge*No charge*Ambulance (if medically necessary)Deductible, then 10% of Allowed BenefitDeductible, then 30% of Allowed BenefitLIFETIME MAXIMUM BENEFITLifetime MaximumPREVENTIVE SERVICESOFFICE VISITS, LABS AND TESTINGEMERGENCY SERVICESHOSPITALIZATION (Members are responsible for applicable physician and facility fees)Outpatient Facility ServicesNo charge*Deductible, then 30% of Allowed BenefitOutpatient Physician ServicesNo charge*Deductible, then 30% of Allowed BenefitInpatient Facility ServicesNo charge*Deductible, then 30% of Allowed BenefitInpatient Physician ServicesNo charge*Deductible, then 30% of Allowed BenefitCST3448-1P (9/17) DC 51-199, 200 Option 22
BluePreferred Summary of BenefitsServicesIn-Network You Pay1,2Out-of-Network You Pay1,3Home Health Care(limited to 90 visits per episode of care)Deductible, then 10% of Allowed BenefitDeductible, then 30% of Allowed BenefitHospice (limited to a maximum 180 dayHospice eligibility period)Deductible, then 10% of Allowed BenefitDeductible, then 30% of Allowed BenefitSkilled Nursing Facility(limited to 60 days/benefit period)Deductible, then 10% of Allowed BenefitDeductible, then 30% of Allowed BenefitPreventive Prenatal and Postnatal OfficeVisitsNo charge*Deductible, then 30% of Allowed BenefitDelivery and Facility ServicesNo charge*Deductible, then 30% of Allowed BenefitNursery Care of NewbornNo charge*Deductible, then 30% of Allowed BenefitArtificial and Intrauterine Insemination7Not coveredNot coveredIn Vitro Fertilization Procedures7Not coveredNot coveredHOSPITAL ALTERNATIVESMATERNITYMENTAL HEALTH AND SUBSTANCE USE DISORDER (Members are responsible for applicable physician and facility fees)Inpatient Facility ServicesNo charge*Deductible, then 30% of Allowed BenefitInpatient Physician ServicesNo charge*Deductible, then 30% of Allowed BenefitOutpatient Facility ServicesNo charge*Deductible, then 30% of Allowed BenefitOutpatient Physician ServicesNo charge*Deductible, then 30% of Allowed BenefitOffice Visits 20 per visitDeductible, then 30% of Allowed BenefitMedication Management 20 per visitDeductible, then 30% of Allowed BenefitDurable Medical EquipmentDeductible, then 10% of Allowed BenefitDeductible, then 30% of Allowed BenefitHearing Aids (ages 0-18)Deductible, then 10% of Allowed BenefitDeductible, then 30% of Allowed BenefitRoutine Exam (limited to 1 visit/benefitperiod) 10 per visit at participating visionproviderCareFirst pays 33, you pay balanceEyeglasses and Contact LensesDiscounts from participating VisionCentersNot coveredMEDICAL DEVICES AND SUPPLIESVISIONNote: Allowed Benefit is the fee that participating providers in the network have agreed to accept for a particular service. The participatingprovider cannot charge the member more than this amount for any covered service. Example: Dr. Carson charges 100 to see a sick patient.To be part of CareFirst’s network, he has agreed to accept 50 for the visit. The member will pay their copay/coinsurance and deductible (ifapplicable) and CareFirst will pay the remaining amount up to 50.* No copayment or coinsurance.1When multiple services are rendered on the same day by more than one provider, Member payments are required for each provider.2 In-network: When covered services are rendered by a provider in the Preferred Provider network, care is reimbursed at the in-network level.In-network coinsurances are based on a percentage of the Allowed Benefit. The Allowed Benefit is generally the contracted rates or feeschedules that Preferred Providers have agreed to accept as payment for covered services. These payments are established by CareFirstBlueCross BlueShield (CareFirst), however, in certain circumstances, the Allowed Benefit for a Preferred Provider may be established by law.3 Out-of-network: When covered services are rendered by a provider not in the Preferred Provider network, care is reimbursed as out-ofnetwork. Out-of-network coinsurances are based on a percentage of the Allowed Benefit. The Allowed Benefit is generally the contractedrates or fee schedules that Preferred Providers have agreed to accept as payment of covered services. These payments are established byCareFirst, however, in certain circumstances, the Allowed Benefit for an out-of-network provider may be established by law. When servicesare rendered by Non-Preferred Providers, charges in excess of the Allowed Benefit are the member’s responsibility.4For family coverage only: When one family member meets the individual deductible, they can start receiving benefits. Each family membercannot contribute more than the individual deductible amount. The family deductible must be met before the remaining family members canstart receiving benefits5For Family coverage only: When one family member meets the individual out-of-pocket maximum, their services will be covered at 100% upto the Allowed Benefit. Each family member cannot contribute more than the individual out-of-pocket maximum amount. The family out-ofpocket maximum must be met before the services for all remaining family members will be covered at 100% up to the Allowed Benefit.6Plan has separate out-of-pocket maximums for medical and drug expenses which accumulate independently.7Members who are unable to conceive have coverage for the evaluation of infertility services performed to confirm an infertility diagnosis, andsome treatment options for infertility. Preauthorization required.Not all services and procedures are covered by your benefits contract. This summary is for comparison purposes only and does not createrights not given through the benefit plan.The benefits described are issued under form numbers: DC/CF/GC (R. 1/13); DC/CF/BP/EOC (R. 11/09); DC/GHMSI/DOL APPEAL (R. 11/11); DC/CF/BP/DOCS (7/08); DC/CF/BP/SOB (7/08); DC/CF/ATTC (R. 1/10); DC/CF/RX3 (R. 1/15); and any amendments.CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Crossand Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.CST3448-1P (9/17) DC 51-199, 200 Option 22
Pharmacy Program Summary of BenefitsSmithsonian InstitutionFormulary 3 5-Tier 100 Deductible 10/30/55 Specialty 50%/50%Plan FeatureAmount You PayDescriptionIndividual Deductible 100If you meet your deductible, you will pay a different copay orcoinsurance depending on the drug tier. Drugs not subject toany deductible are noted below.Family Deductible 200If your family has met the deductible maximum, all memberswill pay the copays associated with the drugs prescribed. Noone family member may contribute more than the individualdeductible amount to the family deductible.Out-of-Pocket MaximumSee medical summaryof benefits for annualout‑of‑pocket amountIf you reach your out-of-pocket maximum, CareFirst or CareFirstBlueChoice will pay 100% of the applicable allowed benefitfor most covered services for the remainder of the year. Alldeductibles, copays, coinsurance and other eligible out-of-pocketcosts count toward your out-of-pocket maximum, except balancebilled amounts.Preventive Drugs(up to a 34-day supply) 0(not subject to deductible)A preventive drug is a prescribed medication or item on CareFirst’sPreventive Drug List.*Oral Chemotherapy Drugsand Diabetic Supplies(up to a 34-day supply) 0(not subject to deductible)Diabetic supplies include needles, lancets, test strips andalcohol swabs.Generic Drugs (Tier 1)(up to a 34-day supply) 10Generic drugs are covered at this c
lenses offered by CareFirst BlueCross BlueShield and CareFirst BlueChoice, through the Davis Vision, Inc. national network of providers. How the plan works How do I find a provider? To find a provider, go to carefirst.com and utilize the Find a Provider feature or call Davis Vision at 800-783-5602 for a list of network providers closest to you.
