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BlueChoice HMO Open Access Summary of BenefitsMundo Verde Bilingual Public Charter SchoolNon-Integrated DeductibleIn-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 wellness program as part of your medical plan. Youalso have Blue Rewards, an incentive program where you can get rewarded for completingcertain activities.Visit www.carefirst.com/myaccount formore information.ANNUAL MEDICAL DEDUCTIBLE (Benefit Period)2$500Individual$1,000FamilyANNUAL OUT-OF-POCKET MAXIMUM (Benefit Period)3$4,500 Individual/$9,000 FamilyMedical4Combined with in-network out-of-pocket maximumPrescription Drug4PREVENTIVE SERVICESNo charge*Well-Child Care(including exams & immunizations)No charge*Adult Physical Examination (includingroutine GYN visit)No charge*Breast Cancer ScreeningNo charge*Pap TestNo charge*Prostate Cancer ScreeningNo charge*Colorectal Cancer ScreeningPCP AND SPECIALIST SERVICES$200 per visitFACILITY CHARGE5—In addition to thephysician copays/coinsurances listed below,if a service is rendered on a hospitalcampus, ADD facility charge if applicableVirtual Connect through CloseKnit- No charge* for members age 18 and older(closeknithealth.com)All other providers- $10 per visitOffice Visits for Illness—PCP5,6,7$10 per visitConvenience Care (retail health clinics suchas CVS MinuteClinic or WalgreensHealthcare Clinic)$20 per visitOffice Visits for Illness—Specialist5,6$20 per visitAllergy Testing5$20 per visitAllergy Shots5$20 per visitPhysical, Speech, and OccupationalTherapy5,8(limited to 30 visits/injury/benefit period)$20 per visitChiropractic Services5(limited to 20 visits/benefit period)$20 per visitAcupuncture5(limited to 20 visits/benefit period)CST6314-1P (8/23) ■ DC ■ 51+ Option 2-S (Smart Selections)

In-Network You Pay1ServicesEMERGENCY SERVICES$40 per visitUrgent Care Center(such as Patient First or Express Care)Hospital Emergency Room ServicesDeductible, then $200 per visit (waived if admitted)■ FacilityNo charge* after deductible■ PhysicianDeductible, then $50 per serviceAmbulance (if medically necessary)DIAGNOSTIC SERVICESLabs9$10 per visit■ LabCorpDeductible, then $100 per visit■ Hospital(Preauthorization required)X-ray9$20 per visit■ Non-Hospital/Freestanding FacilityDeductible, then $150 per visit■ Hospital(Preauthorization required)Imaging9$60 per visit■ Non-Hospital/Freestanding FacilityDeductible, then $200 per visit■ Hospital(Preauthorization required)HOSPITALIZATION—(Members are responsible for both physician and facility fees)Outpatient Surgical Center Services$100 per visit■ Facility$20 per visit■ PhysicianOutpatient Hospital Surgical ServicesDeductible, then $200 per visit■ FacilityDeductible, then $20 per visit■ PhysicianInpatient Hospital ServicesDeductible, then $300 per day ($1,500 maximum per admission)■ FacilityDeductible, then $20 per visit■ PhysicianHOSPITAL ALTERNATIVESNo charge*Home Health CareNo charge*Hospice(Inpatient—limited to 30 days;Outpatient—unlimited during Hospiceeligibility period)Deductible, then $200 per admissionSkilled Nursing Facility (limited to 60days/benefit period)MATERNITYNo charge*Preventive Prenatal and Postnatal OfficeVisitsDeductible, then $300 per day ($1,500 maximum per admission)Delivery and Facility ServicesNot coveredArtificial and Intrauterine Insemination5,10No charge* after deductibleIn Vitro Fertilization Procedures5,10(limited to $100,000 lifetime maximum)MENTAL HEALTH AND SUBSTANCE USE DISORDER—(Members are responsible for both physician and facility fees)Virtual Connect through CloseKnit- No charge* for members age 18 and older(closeknithealth.com)All other providers- $10 per visitOffice Visits7Outpatient Services$60 per visit■ Facility$20 per visit■ PhysicianCST6314-1P (8/23) ■ DC ■ 51+ Option 2-S (Smart Selections)BlueChoice HMO Open Access Summary of Benefits

In-Network You Pay1ServicesInpatient ServicesDeductible, then $300 per day ($1,500 maximum per admission)■ FacilityDeductible, then $20 per visit■ PhysicianMEDICAL DEVICES AND SUPPLIESDeductible, then 25% of Allowed BenefitDurable Medical EquipmentNot coveredHearings AidsVISION$10 per visit at participating vision providerRoutine Exam (limited to 1 visit/benefitperiod)Discounts from participating vision centersEyeglasses and Contact LensesNote: Allowed Benefit is the fee that participating, in-network providers have agreed to accept for a particular covered service. The provider cannotcharge 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’snetwork, he has agreed to accept $50 for the visit. The member will pay their copay/coinsurance and deductible (if applicable) and CareFirst willpay 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.2For 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 benefits.3For Family coverage only: When one family member meets the individual out-of-pocket maximum, their services will be covered at 100% up tothe Allowed Benefit. Each family member cannot contribute more than the individual out-of-pocket maximum amount. The family out-of-pocketmaximum must be met before the services for all remaining family members will be covered at 100% up to the Allowed Benefit.4Plan has an integrated medical and prescription drug out-of-pocket maximum.5If a service is rendered on a hospital campus you could receive two bills, one from the physician and one from the facility.6“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 atelemedicine service.7CloseKnit is a registered Trademark owned by, and is the trade name of, Atlas Health, LLC. Atlas Health, LLC d/b/a CloseKnit does not provideBlue Cross Blue Shield products or services and is providing telehealth services to CareFirst members.8There are no limits for children under age 21 when Physical, Speech or Occupational Therapy is included as part of Habilitative Services.9Members accessing laboratory services inside the CareFirst Service area (Maryland, D.C., Northern Virginia) must use LabCorp as their Lab Testfacility and a non-hospital/freestanding facility for X-rays and specialty Imaging.10Members 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 requiredReminder: To enroll in HMO, HMO Referral and Plus plans, members must live or work within the CareFirst service area of Maryland,Washington, D.C. or Northern Virginia.Note: Upon enrollment in CareFirst BlueChoice, you will need to select a Primary Care Provider (PCP). To select a PCP, go towww.carefirst.com/findadoc for the most current listing of PCPs from our online provider directory. You may also call the MemberServices number on the back of your CareFirst ID card for assistance in selecting a PCP or obtaining a printed copy of the CareFirstBlueChoice provider directory.Not all services and procedures are covered by your benefits contract. This summary is for comparison purposes only and does notcreate rights not given through the benefit plan.The benefits described are issued under form numbers: DC/CFBC/GC (R. 1/19); DC/CFBC/EOC (R. 6/09); DC/CFBC/DOL APPEAL (R. 1/22);DC/CFBC/LG/HMO/DOCS (6/16); DC/CFBC/LG/HMO/SOB (6/16); DC/CFBC/LG/INCENT (1/19); DC/CFBC/RX3 (R. 1/18); DC/CFBC/ATTC (R. 1/10); andany amendments.CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross® and Blue Shield®and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association ofindependent Blue Cross and Blue Shield Plans.CST6314-1P (8/23) ■ DC ■ 51+ Option 2-S (Smart Selections)BlueChoice HMO Open Access Summary of Benefits