Return to flip book view

BlueChoice HMO Open Access HSA/HRA Summary of BenefitsMundo Verde Bilingual Public Charter SchoolIntegrated 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 DEDUCTIBLE (Benefit period)2$2,000Individual$4,000FamilyANNUAL OUT-OF-POCKET MAXIMUM (Benefit period)3$4,000 Individual/$8,000 FamilyMedical4Combined with in-network medical out-of-pocket maximumPrescription Drug4LIFETIME MAXIMUM BENEFITNoneLifetime MaximumPREVENTIVE 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 ScreeningOFFICE VISITS, LABS AND TESTINGVirtual Connect through CloseKnit- No charge* after deductible for members age 18 andolder (closeknithealth.com)All other providers- No charge* after deductibleOffice Visits for Illness5No charge* after deductibleImaging (MRA/MRS, MRI, PET & CAT scans)6No charge* after deductibleLab6No charge* after deductibleX-ray6No charge* after deductibleAllergy TestingNo charge* after deductibleAllergy ShotsNo charge* after deductiblePhysical, Speech and Occupational Therapy7(limited to 30 visits/injury/benefit period)No charge* after deductibleChiropractic(limited to 20 visits/benefit period)No charge* after deductibleAcupuncture(limited to 20 visits/benefit period)EMERGENCY SERVICESNo charge* after deductibleUrgent Care CenterNo charge* after deductibleEmergency Room—Facility ServicesNo charge* after deductibleEmergency Room—Physician ServicesNo charge* after deductibleAmbulance (if medically necessary)CST6315-1P (8/23) ■ DC ■ 51+ Option 11 (Hybrid)

In-Network You Pay1ServicesHOSPITALIZATION—(Members are responsible for both physician and facility fees)No charge* after deductibleOutpatient Facility ServicesNo charge* after deductibleOutpatient Physician ServicesNo charge* after deductibleInpatient Facility ServicesNo charge* after deductibleInpatient Physician ServicesHOSPITAL ALTERNATIVESNo charge* after deductibleHome Health CareNo charge* after deductibleHospiceNo charge* after deductibleSkilled Nursing FacilityMATERNITYNo charge*Preventive Prenatal and Postnatal OfficeVisitsNo charge* after deductibleDelivery and Facility ServicesNo charge* after deductibleNursery Care of NewbornNot coveredArtificial and Intrauterine Insemination8No charge* after deductibleIn Vitro Fertilization Procedures8(limited to $100,000 lifetime maximum)MENTAL HEALTH AND SUBSTANCE USE DISORDER—(Members are responsible for applicable physician and facility fees)No charge* after deductibleInpatient Facility ServicesNo charge* after deductibleInpatient Physician ServicesNo charge* after deductibleOutpatient Facility ServicesNo charge* after deductibleOutpatient Physician ServicesVirtual Connect through CloseKnit- No charge* after deductible for members age 18 andolder (closeknithealth.com)All other providers- No charge* after deductibleOffice Visits5No charge* after deductibleMedication ManagementMEDICAL DEVICES AND SUPPLIESDeductible, then 25% of Allowed BenefitDurable Medical EquipmentNot coveredHearing Aids for ages 0-18VISION$10 per visitRoutine Exam (limited to 1 visit/benefitperiod)Discounts from participating Vision CentersEyeglasses and Contact LensesCST6315-1P (8/23) ■ DC ■ 51+ Option 11 (Hybrid)BlueChoice HMO Open Access HSA/HRA Summary of Benefits

Note: Allowed Benefit is the fee that participating providers in the network have agreed to accept for a particular service. The participating providercannot charge the member more than this amount for any covered service. Example: Dr. Carson charges $100 to see a sick patient. To be part ofCareFirst’s network, he has agreed to accept $50 for the visit. The member will pay their copay/coinsurance and deductible (if applicable) andCareFirst 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.2For family coverage only: The family deductible must be met before any member starts receiving benefits. The deductible may be met by onemember or any combination of members.3For family coverage only: The family out-of-pocket maximum must be met before any member's services will be covered at 100% up to theAllowedBenefit. The out-of-pocket maximum may be met by one member or any combination of members.4Plan has integrated medical and prescription drug out-of-pocket maximum.5CloseKnit 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.6Members 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.7There are no limits for children under age 21 when Physical, Speech or Occupational Therapy is included as part of Habilitative Services.8Members 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.Reminder: 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/DOCS(R. 6/09); DC/BC-OOP/SOB (R. 6/09); DC/BC-OOP/SOB HDHP (R. 7/07); DC/CFBC/LG/INCENT (R. 1/19); DC/CFBC/RX3 (R. 1/18); DC/CFBC/ATTC (R.1/10) and any 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.CST6315-1P (8/23) ■ DC ■ 51+ Option 11 (Hybrid)BlueChoice HMO Open Access HSA/HRA Summary of Benefits