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BlueChoice Advantage HSA/HRA Silver 1600 Summary of BenefitsIntegrated DeductibleOut-of-Network You Pay1In-Network You Pay1ServicesVisit www.carefirst.com/doctor to locate providers and facilities24-HOUR NURSE ADVICE LINEWhen your doctor is not available, call 800-535-9700 to speak with a registered nurseabout your health questions and treatment options.Free advice from a registered nurse.Visit www.carefirst.com/needcare to learnmore about your options for care.WELLBEING PROGRAM & BLUE REWARDSYou have access to a comprehensive wellbeing program as part of your medical plan.You also have Blue Rewards, an incentive program where you can get rewarded forcompleting certain activities.Visit www.carefirst.com/sharecare for moreinformation.ANNUAL MEDICAL DEDUCTIBLE (Benefit Period)2,3$3,200 Individual/$6,400 Family(aggregate)$1,600 Individual/$3,200 Family(aggregate)Individual/FamilyANNUAL OUT-OF-POCKET MAXIMUM (Benefit Period)2,4,5$14,000 Individual/$28,000 Family(separate)$7,500 Individual/$15,000 Family(separate)Individual/FamilyPREVENTIVE SERVICESNo charge*No charge*Well-Child Care(including exams & immunizations)No charge* after deductibleNo charge*Adult Physical Examination (including routineGYN visit)No charge*No charge*Breast Cancer ScreeningNo charge*No charge*Pap TestNo charge*No charge*Prostate Cancer ScreeningNo charge* after deductibleNo charge*Colorectal Cancer ScreeningPCP AND SPECIALIST SERVICESDeductible, then $150 per visitDeductible, then $50 per visitFACILITY CHARGE6—In addition to thephysician copays/coinsurances listed below,if a service is rendered on a hospital campus,ADD facility charge if applicable (also appliesto Artificial Insemination and In VitroFertilization on page 2)Deductible, then $70 per visitDeductible, then $25 per visitOffice Visits for Illness—PCP6,7Deductible, then $70 per visitDeductible, then $50 per visitOffice Visits for Illness—Specialist6,7Deductible, then $70 per visitDeductible, then $50 per visitAllergy Testing6Deductible, then $70 per visitDeductible, then $50 per visitAllergy Shots6Deductible, then $70 per visitDeductible, then $50 per visitPhysical, Speech, and Occupational Therapy6Deductible, then $70 per visitDeductible, then $50 per visitChiropractic6Deductible, then $70 per visitDeductible, then $50 per visitAcupuncture6IMMEDIATE AND EMERGENCY SERVICESDeductible, then $70 per visitDeductible, then $25 per visitConvenience Care (retail health clinics suchas CVS MinuteClinic or Walgreens HealthcareClinic)In-network deductible, then $100 per visitDeductible, then $100 per visitUrgent Care Center8(such as Patient First or ExpressCare)Hospital Emergency Room Services8In-network deductible, then $350 per visit(waived if admitted)Deductible, then $350 per visit (waived ifadmitted) FacilityIn-network deductible, then $85 per visitDeductible, then $85 per visit PhysicianIn-network deductible, then $85 perserviceDeductible, then $85 per serviceAmbulance (if medically necessary)8SUM6218-1P (2/23) ■ DC ■ 2023 2-50 ACA Compliant
Out-of-Network You Pay1In-Network You Pay1ServicesDIAGNOSTIC SERVICESLabs9,Deductible, then $75 per visitDeductible, then $25 per visit Non-Hospital/Freestanding FacilityDeductible, then $250 per visitDeductible, then $150 per visit HospitalX-ray9Deductible, then $100 per visitDeductible, then $50 per visit Non-Hospital/Freestanding FacilityDeductible, then $300 per visitDeductible, then $200 per visit HospitalImaging9Deductible, then $300 per visitDeductible, then $250 per visit Non-Hospital/Freestanding FacilityDeductible, then $550 per visitDeductible, then $500 per visit HospitalSURGERY AND HOSPITALIZATION—(Members are responsible for both physician and facility fees)Outpatient Surgery (Non-Hospital)Deductible, then $400 per visitDeductible, then $300 per visit FacilityDeductible, then $70 per visitDeductible, then $50 per visit PhysicianOutpatient Surgery (Hospital)Deductible, then $600 per visitDeductible, then $500 per visit FacilityDeductible, then $100 per visitDeductible, then $85 per visit PhysicianInpatient Surgery and Hospital ServicesDeductible, then $600 per admissionDeductible, then $500 per admission FacilityDeductible, then $100 per visitDeductible, then $85 per visit PhysicianHOSPITAL ALTERNATIVESDeductible, then $70 per visitNo charge* after deductibleHome Health Care(limited to 90 visits per episode of care)Deductible, then $70 per visitNo charge* after deductibleHospice(Inpatient—limited to 60 days per hospiceeligibility period; Outpatient—limited to 180day hospice eligibility period)Deductible, then $70 per admissionDeductible, then $50 per admissionSkilled Nursing Facility(limited to 60 days/benefit period)MATERNITYDeductible, then $70 per visitNo charge*Preventive Prenatal and Postnatal Office VisitsDeductible, then $600 per admissionDeductible, then $500 per admissionDelivery and Facility ServicesNot coveredNot coveredArtificial and Intrauterine Insemination6,10Not coveredNot coveredIn Vitro Fertilization Procedures6,10MENTAL HEALTH AND SUBSTANCE USE DISORDER—(Members are responsible for both physician and facility fees)Deductible, then $70 per visitDeductible, then $25 per visitOffice VisitsOutpatient ServicesDeductible, then $70 per visitDeductible, then $50 per visit FacilityDeductible, then $70 per visitDeductible, then $50 per visit PhysicianInpatient ServicesDeductible, then $600 per admissionDeductible, then $500 per admission FacilityDeductible, then $70 per visitDeductible, then $50 per visit PhysicianMEDICAL DEVICES AND SUPPLIESDeductible, then 45% of Allowed BenefitDeductible, then 25% of Allowed BenefitDurable Medical EquipmentNot coveredNot coveredHearing AidsSUM6218-1P (2/23) ■ DC ■ 2023 2-50 ACA CompliantBlueChoice Advantage HSA/HRA Silver 1600 Summary of Benefits
Out-of-Network You Pay1In-Network You Pay1ServicesPRESCRIPTION DRUGS11,12Visit www.carefirst.com/acarx to locate Formulary ListFormulary ListSubject to combined medical and prescription drug deductible(waived for preferred and non-preferred brand insulin)Annual Prescription Drug DeductibleNo charge*Preventive DrugsNo charge* after deductibleDiabetic Supplies, Oral Chemo Drugs andMedication Assisted Treatment Drugs30-day supply Deductible, then $15;90-day supply Deductible, then $30 (maintenance drugs only)Generic Drugs30-day supply Deductible, then $45;90-day supply Deductible, then $90 (maintenance drugs only)Preferred Brand Drugs13(Preferred Insulin$0)30-day supply Deductible, then $65;90-day supply Deductible, then $130 (maintenance drugs only)Non-preferred Brand Drugs14(Non-preferredInsulin capped at $30 for 30 days/$60 for 90days)30-day supply Deductible, then 50% up to $100 maximum;90-day supply Deductible, then 50% up to $200 maximum (maintenance drugs only)Preferred Specialty Drugs (must be filledthrough Exclusive Specialty PharmacyNetwork)30-day supply Deductible, then 50% up to $150 maximum;90-day supply Deductible, then 50% up to $300 maximum (maintenance drugs only)Non-Preferred Specialty Drugs (must be filledthrough Exclusive Specialty PharmacyNetwork)PEDIATRIC VISION—(Through the end of the calendar year in which the dependent turns 19)Total charge minus $40 reimbursementNo charge*Routine Exam (limited to 1 visit/benefit period)Reimbursements applyNo charge*Frames and Contact Lenses—PediatricCollection OnlyReimbursements applyNo charge*Spectacle LensesPEDIATRIC DENTAL—(Through the end of the calendar year in which the dependent turns 19)$50$25Annual Dental Deductible20% of Allowed BenefitNo charge*Class I Preventative & Diagnostic Services—Exams (2 per year). Cleanings (2 per year),fluoride treatments (2 per year), sealants,bitewing X-rays (2 per year), full mouth X-ray(one every 3 years)Deductible, then 40% of Allowed BenefitDeductible, then 20% of Allowed BenefitClass II Basic Services—Fillings (amalgam orcomposite), simple extractions, non-surgicalperiodonticsDeductible, then 40% of Allowed BenefitDeductible, then 20% of Allowed BenefitClass III Major Services—Surgical periodontics,endodontics, oral surgeryDeductible, then 65% of Allowed BenefitDeductible, then 50% of Allowed BenefitClass IV Major Services—Restorative Crowns,dentures, inlays and onlays65% of Allowed Benefit50% of Allowed BenefitClass V Medically Necessary OrthodonticServicesSUM6218-1P (2/23) ■ DC ■ 2023 2-50 ACA CompliantBlueChoice Advantage HSA/HRA Silver 1600 Summary of Benefits
Note: Allowed Benefit is the fee that providers in the network have agreed to accept for a particular service. The provider cannot charge the member more thanthis 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 thevisit. The member will pay their copay/coinsurance and deductible (if applicable) 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.2In- and out-of-network deductible and out-of-pocket maximums do not contribute to each other.3Aggregate - For family coverage only: The family deductible must be met before any member starts receiving benefits. The deductible may be met by one memberor any combination of members.4Separate - For family coverage only: When one family member meets the individual out-of-pocket maximum, their services will be covered at 100% up to theAllowed Benefit. Each family member cannot contribute more than the individual out-of-pocket maximum amount. The family out-of-pocket maximum must bemet before the services for all remaining family members will be covered at 100% up to the Allowed Benefit. The out-of-pocket maximum includes deductibles,copays and coinsurance.5All drug costs are subject to the in-network out-of-pocket maximum.6If a service is rendered on a hospital campus you could receive two bills, one from the physician and one from the facility.7“Telemedicine services” refers to the use of a combination of interactive audio, video, or other electronic media used for the purpose of diagnosis, consultation,or treatment. Use of audio-only telephone, electronic mail message (e-mail), or facsimile transmission (FAX) is not considered a telemedicine service.8If the out-of-network benefit is listed as contributing toward the in-network deductible, then it also contributes toward the in-network out-of-pocket maximum.9Members accessing laboratory services inside the CareFirst Service area (Maryland, D.C., Northern Virginia) must use LabCorp as their Lab Test facility and anon-hospital/freestanding facility for X-rays and specialty Imaging for In-Network benefits. Services performed by any other provider, while inside the CareFirstService area will be considered Out-of-Network. Members accessing laboratory, X-rays, and specialty Imaging services outside of Maryland, D.C. or NorthernVirginia, may use any participating BlueCard PPO facility and receive in-network benefits.10Members who are unable to conceive have coverage for the evaluation of infertility services performed to confirm an infertility diagnosis, and some treatmentoptions for infertility. Preauthorization required.11Except for emergency services or out-of-area urgent care, if a member goes to a non-participating pharmacy, the member is responsible for the copay/coinsurancefor the drug plus the difference between the allowed charge and the actual charge for that drug (called balance billed amount). The balance billed amount doesnot contribute to the out-of-pocket maximum.12Benefits for SpecialtyDrugs are only available when Specialty Drugs are purchased from and dispensed by a specialty Pharmacy in the Exclusive Specialty PharmacyNetwork.13If a Generic drug becomes available for a Preferred Brand drug, the Preferred Brand drug moves to the Non-preferred Brand drug tier.14If a provider prescribes a Non-preferred Brand drug, and the Member selects the Non-preferred Brand drug when a Generic drug is available, the Member shallpay the applicable Copayment or Coinsurance as stated in the Schedule of Benefits plus the difference between the price of the Non-preferred Brand drug andthe Generic drug up to the cost of the drug. This amount will not contribute to the Out-of-Pocket Maximum.Not all services and procedures are covered by your benefits contract. This summary is for comparison purposes only and does not create rights notgiven through the benefit plan.The benefits described are issued under form numbers: In-Network: DC/CFBC/SHOP/GC (R 1/19); DC/CFBC/SHOP/HMO POS/EOC (R. 1/20); DC/CFBC/DOL APPEAL(R. 1/22); DC/CFBC/SHOP/ADV IN DOCS (R. 1/20); DC/CFBC/SHOP/2021 AMEND (1/21); DC/CFBC/SHOP/2022 AMEND (1/22); DC/CFBC/SG/BC ADV IN BF HSA/SIL 1500(1/22); DC/CFBC/SG/POS IN CDH/BRZ 6100 (1/22); DC/CFBC/SG/POS IN CDH/SIL 1500 (1/22); DC/CFBC/SG/POS IN CDH/SIL 2500 (1/22); DC/CFBC/SG/POS IN CDH/SIL3000 (1/22); DC/CFBC/SG/POS IN/GOLD 500 (1/22); DC/CFBC/SG/POS IN/GOLD 1000 (1/22); DC/CFBC/SG/POS IN CDH/GOLD 1500 (1/22); DC/CFBC/SG/POS INCDH/GOLD 1500 90 (1/22); DC/CFBC/SG/POS IN CDH/SIL 2000 (1/22); DC/CFBC/SG/POS IN CDH/SIL 2100 70 (1/22); DC/CFBC/SG/POS IN CDH/SIL 3000 70 (1/22);DC/CFBC/SG/POSIN/VBRZ6000(1/22);DC/CFBC/SG/POSIN/GOLD0(1/22);DC/CFBC/SG/POSIN/GOLD3000(1/22);DC/CFBC/SG/POSIN/PLAT0(1/22);DC/CFBC/SG/POSIN/SIL 4000 (1/22); DC/CFBC/SG/POS IN/SIL 5000 (1/22); DC/CFBC/ADV/BLCRD (R. 6/18); DC/CFBC/ADV/MEM/BLCRD (R. 6/18); DC/CFBC/ANCILLARY AMEND (10/12);DC/CFBC/SG/AUTH AMEND/ADV (1/20); DC/CFBC/PT PROTECT (9/10); DC/CFBC/SG/INCENT (R. 1/21); DC/CFBC/SHOP/ELIG (R. 1/21) and any amendmentsOut-of-Network: DC/CF/SHOP/GC (R 1/19); DC/CF/SHOP/POS OON/EOC (R. 1/20); DC/GHMSI/DOL APPEAL (R. 1/22); DC/CF/SHOP/POS OON/DOCS (R. 1/20);DC/CF/SHOP/POS OON/2021 AMEND (1/21); DC/CF/SHOP/POS OON/2022 AMEND (1/22); DC/CF/SG/BC ADV OON BF HSA/SIL 1500 (1/22); DC/CF/SG/POS OONCDH/BRZ 6100 (1/22); DC/CF/SG/POS OON CDH/SIL 1500 (1/22); DC/CF/SG/POS OON CDH/SIL 2500 (1/22); DC/CF/SG/POS OON CDH/SIL 3000 (1/22); DC/CF/SG/POSOON/GOLD 500 (1/22); DC/CF/SG/POS OON/GOLD 1000 (1/22); DC/CF/SG/POS OON CDH/GOLD 1500 (1/22); DC/CF/SG/POS OON CDH/GOLD 1500 90 (1/22);DC/CF/SG/POS OON CDH/SIL 2000 (1/22); DC/CF/SG/POS OON CDH/SIL 2100 70 (1/22); DC/CF/SG/POS OON CDH/SIL 3000 70 (1/22); DC/CF/SG/POS OON/V BRZ6000 (1/22); DC/CF/SG/POS OON/GOLD 0 (1/22); DC/CF/SG/POS OON/GOLD 3000 (1/22); DC/CF/SG/POS OON/PLAT 0 (1/22); DC/CF/SG/POS OON/SIL 4000 (1/22);DC/CF/SG/POS OON/SIL 5000 (1/22); DC/CF/BLCRD (R. 6/18); DC/CF/MEM/BLCRD (R. 6/18); DC/CF/ANCILLARY AMEND (10/12); DC/CF/SG/AUTH AMEND/POS OON(1/20); DC/CF/PT PROTECT (9/10); DC GHMSI – HEALTH GUARANTY 5/21; DC/CF/SHOP/ELIG (R. 1/21) and any amendments.CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShieldCommunity Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. In the District ofColumbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the businessname of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). Group Hospitalization and Medical Services, Inc., Trusted HealthPlan (District of Columbia, Inc., CareFirst BlueChoice, Inc., First Care, Inc., and The Dental Network, Inc. are independent licensees ofthe Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered servicemarks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.SUM6218-1P (2/23) ■ DC ■ 2023 2-50 ACA CompliantBlueChoice Advantage HSA/HRA Silver 1600 Summary of Benefits
Notice of Nondiscrimination andAvailability of Language Assistance Services(UPDATED 8/5/19)CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc., CareFirst Diversified Benefits and all of their corporateaffiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race,color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently becauseof race, color, national origin, age, disability or sex.CareFirst:Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats)Provides free language services to people whose primary language is not English, such as:Qualified interpretersInformation written in other languagesIf you need these services, please call 855-258-6518.If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis ofrace, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinatorby mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available tohelp you.To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinatoras indicated below. Please do not send payments, claims issues, or other documentation to this office.Civil Rights Coordinator, Corporate Office of Civil RightsMailing Address P.O. Box 8894Baltimore, Maryland 21224Email Address civilrightscoordinator@carefirst.comTelephone Number 410-528-7820Fax Number 410-505-2011You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for CivilRights electronically through the Office for Civil Rights Complaint portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 20201800-368-1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and MedicalServices, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc.,The DentalNetwork and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia andMaryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care,Inc. of Maryland (used in VA by: First Care, Inc.). The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registeredservice marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.SUM6218-1P (2/23) ■ DC ■ 2023 2-50 ACA Compliant
Foreign Language Assistance አማርኛ (Amharic) ማሳሰቢያ፦ ይህ ማስታወቂያ ስለ መድን ሽፋንዎ መረጃ ይዟል። ከተወሰኑ ቀነ-ገደቦች በፊት ሊፈጽሟቸውየሚገቡ ነገሮች ሊኖሩ ስለሚችሉ እነዚህን ወሳኝ ቀናት ሊይዝ ይችላል። ይኽን መረጃ የማግኘት እና ያለምንም ክፍያ በቋንቋዎእገዛ የማግኘት መብት አለዎት። አባል ከሆኑ ከመታወቂያ ካርድዎ በስተጀርባ ላይ ወደተጠቀሰው የስልክ ቁጥር መደወል ይችላሉ።አባል ካልሆኑ ደግሞ ወደ ስልክ ቁጥር 855-258-6518 ደውለው 0ን እንዲጫኑ እስኪነገርዎ ድረስ ንግግሩን መጠበቅ አለብዎ።አንድ ወኪል መልስ ሲሰጥዎ፣ የሚፈልጉትን ቋንቋ ያሳውቁ፣ ከዚያም ከተርጓሚ ጋር ይገናኛሉ። SUM6218-1P (2/23) ■ DC ■ 2023 2-50 ACA Compliant
SUM6218-1P (2/23) ■ DC ■ 2023 2-50 ACA Compliant
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