BENEFITS GUIDE
Employee Benefits Guide December 1, 2022 – November 30, 2023
Prepared by
CONTENT
Welcome
3
Medical Benefits - BlueChoice HMO
4
Medical Benefits - BluePreferred
6
Medical Benefits - HealthyBlue 2.0
8
Additional Medical Services
11
Pharmacy Rx
13
Flexible Spending Account
14
Dental Benefits
17
Vision Benefits
19
Basic Life and Disability
21
Voluntary Life and AD&D
22
Disability
23
Glossary Of Insurance Terms
26
Key Contacts
27
W E L C O M E
About This Guide This guide describes the benefit plans available to you as an employee. The details of these plans are contained in the official plan documents, including some insurance contracts. This guide is meant only to cover the major points of each plan. It does not contain all of the details that are included in your summary plan description (as described by the Employees Retirement Income Security Act). If there is ever a question about one of these plans, or if there is a conflict between the information in this guide and the formal language of the plan documents, the formal wording in the plan documents will govern. Please note that the benefits described in this guide may be changed at any time and do not represent a contractual obligation.
Making Changes Generally, you may only make changes to your benefits selections during the annual benefits open enrollment period. However, you may make changes to your current coverage if you have a life status change. Eligible status changes would be:
Initial Enrollment Eligibility: If you are an active, full-time employee working at least 30 hours per week, you are eligible to apply for coverage beginning on your date of hire. Benefits Begin: Coverage is effective first of the month following date of hire. You must apply for benefits within 30 days of employment. Please allow two weeks for processing once your enrollment form has been received. Coverage will be retroactive back to your effective date. Benefits End: Medical, Dental and Vision benefits will end at the end of the month after last day worked. At that time,you may be eligible for benefits applicable under COBRA continuation. Life & Disability benefits will end on date of termination. At that time, you may be eligible to convert your Life Insurance policy within 31 days after your termination per policy guidelines. Dependent Coverage: Lawful spouse, and children are eligible dependents for group benefits. Your dependent’s coverage will terminate at the end of the month that he/she reaches age 26. Pre-Tax Payroll Deductions: Some payroll deductions are considered pre-tax — This means that they are taken from your gross pay before taxes are withheld using a special Section 125 “pre - tax” payroll deduction. This means that you do not pay state, federal, and social security taxes on eligible premiums paid using a payroll deduction. Bottom-line, this means more money
» Marriage, divorce, legal separation or annulment » Birth, adoption or placement for adoption of an eligible child » Death of your spouse or covered child » Change in your spouse’s work status that affect benefits eligibility
» Significant change in your coverage, or your spouse’s health coverage attributable to your spouse’s employment » Change in your child’s eligibility for benefits » Becoming eligible for Medicare or Medicaid » Qualified Medical Child Support Order (QMCSO)
If you have a life status change, you must notify Human Resources within 30 days of the change. Depending on the type of change, you may need to provide proof of the change (for example, a marriage license or birth certificate). If you do not return your enrollment forms to Human Resources within 30 days you will have to wait until the next annual open enrollment period to make benefit changes.
3
In-Network You Pay 1
Services
Visit www.carefirst.com/doctor to locate providers and facilities
24-HOUR NURSE ADVICE LINE
Free advice from a registered nurse. Visit www.carefirst.com/needcare to learn more about your options for care.
When your doctor is not available, call 800-535-9700 to speak with a registered nurse about your health questions and treatment options.
WELLNESS PROGRAM & BLUE REWARDS
Visit www.carefirst.com/myaccount for more information.
You have access to a comprehensive wellness program as part of your medical plan. You also have Blue Rewards, an incentive program where you can get rewarded for completing certain activities.
ANNUAL DEDUCTIBLE (Benefit period) 2
Individual
None
Family
None
ANNUAL OUT-OF-POCKET MAXIMUM (Benefit period) 3
Medical 4
$1,300 Individual/$2,600 Family
Prescription Drug 4
$4,500 Individual/$9,000 Family
LIFETIME MAXIMUM BENEFIT
Lifetime Maximum
None
PREVENTIVE SERVICES
No charge*
Well-Child Care (including exams & immunizations) Adult Physical Examination (including routine GYN visit)
No charge*
Breast Cancer Screening
No charge*
Pap Test
No charge*
Prostate Cancer Screening
No charge*
Colorectal Cancer Screening
No charge*
OFFICE VISITS, LABS AND TESTING
Office Visits for Illness
$10 PCP/$20 Specialist per visit
Imaging (MRA/MRS, MRI, PET & CAT scans) 5
No charge*
Lab 5
No charge*
X-ray 5
No charge*
Allergy Testing
$10 PCP/$20 Specialist per visit
Allergy Shots
$10 PCP/$20 Specialist per visit
Physical, Speech and Occupational Therapy 6 (limited to 30 visits/injury/benefit period)
$20 per visit
Chiropractic (limited to 20 visits/benefit period)
$20 per visit
Acupuncture
Not covered (except when approved or authorized by Plan when used for anesthesia)
EMERGENCY SERVICES
Urgent Care Center
$20 per visit
Emergency Room — Facility Services
$50 per visit (waived if admitted)
Emergency Room — Physician Services
No charge*
Ambulance (if medically necessary)
No charge*
4
BlueChoice HMO
In-Network You Pay 1
Services
HOSPITALIZATION — (Members are responsible for both physician and facility fees)
Outpatient Facility Services
No charge*
Outpatient Physician Services
$10 PCP/$20 Specialist per visit
Inpatient Facility Services
No charge*
Inpatient Physician Services
No charge*
HOSPITAL ALTERNATIVES
Home Health Care
No charge*
Hospice
No charge*
Skilled Nursing Facility
No charge*
MATERNITY
No charge*
Preventive Prenatal and Postnatal Office Visits
Delivery and Facility Services
No charge*
Nursery Care of Newborn
No charge*
Artificial and Intrauterine Insemination 7 (limited to 6 attempts per live birth)
$20 per visit
In Vitro Fertilization Procedures 7
Not covered
MENTAL HEALTH AND SUBSTANCE USE DISORDER — (Members are responsible for applicable physician and facility fees)
Inpatient Facility Services
No charge*
Inpatient Physician Services
No charge*
Outpatient Facility Services
No charge*
Outpatient Physician Services
No charge*
Office Visits
No charge*
Medication Management
No charge*
MEDICAL DEVICES AND SUPPLIES
Durable Medical Equipment
25% of Allowed Benefit
Hearing Aids for ages 0-18
Not covered
VISION
$10 per visit
Routine Exam (limited to 1 visit/benefit period)
Eyeglasses and Contact Lenses
Discounts from participating Vision Centers
Note: Allowed Benefit is the fee that participating providers in the network have agreed to accept for a particular service. The participating provider 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 (i f applicable) and CareFirst will pay the remaining amount up to $50.
No copayment or coinsurance.
1 When multiple services are rendered on the same day by more than one provider, Member payments are required for each provider. 2 For family coverage only: When one family member meets the individual deductible, they can start receiving benefits. Each family member cannot contribute more than the individual deductible amount. The family deductible must be met before the remaining family members can start receiving benefits. 3 For Family coverage only: When one family member meets the individual out-of-pocket maximum, their services will be covered at 100% up to the Allowed Benefit. Each family member cannot contribute more than the individual out-of-pocket maximum amount. The family out-of-pocket maximum must be met before the services for all remaining family members will be covered at 100% up to the Allowed Benefit. 4 Plan has separate out-of-pocket maximums for medical and drug expenses which accumulate independently. 5 Members accessing laboratory services inside the CareFirst Service area (Maryland, D.C., Northern Virginia) must use LabCorp as their Lab Test facility and a non-hospital/freestanding facility for X-rays and specialty Imaging. 6 Visit Limitation does not apply to children ages 2-10 when Physical, Speech and Occupational Therapy is for treatment of Autism Spectrum Disorder. 7 Members who are unable to conceive have coverage for the evaluation of infertility services performed to confirm an infertility diagnosis, and some 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 to www.carefirst.com for the most current listing of PCPs from our online provider directory. You may also call the Member Services toll free phone number on the front of your CareFirst BlueChoice ID card for assistance in selecting a PCP or obtaining a printed copy of the CareFirst BlueChoice provider directory.
Not all services and procedures are covered by your benefits contract. This summary is for comparison purposes only and does not create rights not given through the benefit plan.
5
In-Network You Pay 1,2
Out-of-Network You Pay 1,3
Services
Visit www.carefirst.com/doctor to locate providers and facilities
24-HOUR NURSE ADVICE LINE
Free advice from a registered nurse. Visit www.carefirst.com/needcare to learn more about your options for care.
When your doctor is not available, call 800-535-9700 to speak with a registered nurse about your health questions and treatment options.
WELLNESS PROGRAM & BLUE REWARDS
Visit www.carefirst.com/myaccount for more information.
You have access to a comprehensive wellness program as part of your medical plan. You also have Blue Rewards, an incentive program where you can get rewarded for completing certain activities.
ANNUAL DEDUCTIBLE (Benefit period) 4
Individual
$500
$1,000
Family
$1,000
$2,000
ANNUAL OUT-OF-POCKET MAXIMUM (Benefit period) 5
Medical 6
$1,500 Individual/$3,000 Family
$3,000 Individual/$6,000 Family
Prescription Drug 6
$4,500 Individual/$9,000 Family
All drug costs are subject to in-network out-of-pocket maximum
LIFETIME MAXIMUM BENEFIT
Lifetime Maximum
None
None
PREVENTIVE SERVICES
No charge*
CareFirst pays 100% of Allowed Benefit
Well-Child Care (including exams & immunizations)
No charge*
Deductible, then 20% of Allowed Benefit
Adult Physical Examination (including routine GYN visit)
Breast Cancer Screening
No charge*
CareFirst pays 100% of Allowed Benefit
Pap Test
No charge*
CareFirst pays 100% of Allowed Benefit
Prostate Cancer Screening
No charge*
CareFirst pays 100% of Allowed Benefit
Colorectal Cancer Screening
No charge*
CareFirst pays 100% of Allowed Benefit
OFFICE VISITS, LABS AND TESTING
Office Visits for Illness
$10 per visit
Deductible, then 20% of Allowed Benefit
Imaging (MRA/MRS, MRI, PET & CAT scans)
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Lab
No charge* after deductible
Deductible, then 20% of Allowed Benefit
X-ray
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Allergy Testing
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Allergy Shots
$5 per visit
Deductible, then 20% of Allowed Benefit
Physical, Speech and Occupational Therapy
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Chiropractic
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Acupuncture
Not covered (except when approved or authorized by Plan when used for anesthesia)
Not covered (except when approved or authorized by Plan when used for anesthesia)
EMERGENCY SERVICES
Urgent Care Center
$10 per visit
Deductible, then 20% of Allowed Benefit
Emergency Room — Facility Services
Deductible, plus $50 per visit
Deductible, plus $50 per visit
Emergency Room — Physician Services
No charge* after deductible
No charge* after in-network deductible
Ambulance (if medically necessary)
No charge* after deductible
Deductible, then 20% of Allowed Benefit
HOSPITALIZATION — (Members are responsible for applicable physician and facility fees)
Outpatient Facility Services
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Outpatient Physician Services
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Inpatient Facility Services
No charge* after deductible
Deductible, then 20% of Allowed Benefit
6
Inpatient Physician Services
No charge* after deductible
Deductible, then 20% of Allowed Benefit
BluePreferred
In-Network You Pay 1,2
Out-of-Network You Pay 1,3
Services
HOSPITAL ALTERNATIVES
Home Health Care (limited to 90 visits per episode of care) Hospice (limited to a maximum 180 day Hospice eligibility period) Skilled Nursing Facility (limited to 60 days/benefit period)
No charge* after deductible
Deductible, then 20% of Allowed Benefit
No charge* after deductible
Deductible, then 20% of Allowed Benefit
No charge* after deductible
Deductible, then 20% of Allowed Benefit
MATERNITY
Preventive Prenatal and Postnatal Office Visits No charge*
Deductible, then 20% of Allowed Benefit
Delivery and Facility Services
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Nursery Care of Newborn
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Artificial and Intrauterine Insemination 7
Not covered
Not covered
In Vitro Fertilization Procedures 7
Not covered
Not covered
MENTAL HEALTH AND SUBSTANCE USE DISORDER — (Members are responsible for applicable physician and facility fees)
Inpatient Facility Services
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Inpatient Physician Services
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Outpatient Facility Services
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Outpatient Physician Services
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Office Visits
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Medication Management
No charge* after deductible
Deductible, then 20% of Allowed Benefit
MEDICAL DEVICES AND SUPPLIES
Durable Medical Equipment
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Hearing Aids for ages 0-18
Not covered
Not covered
VISION
Routine Exam (limited to 1 visit/benefit period) $10 per visit at participating vision providers
Total charge minus $33
Eyeglasses and Contact Lenses
Not covered
Discounts from participating Vision Centers
Note: Allowed Benefit is the fee that participating providers in the network have agreed to accept for a particular service. The participating provider 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 deductibl e (if applicable) and CareFirst will pay the remaining amount up to $50.
No copayment or coinsurance.
1 When 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 fee schedules that Preferred Providers have agreed to accept as payment for covered services. These payments are established by CareFirst BlueCross 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-of-network. Out-of-network coinsurances are based on a percentage of the Allowed Benefit. The Allowed Benefit is generally the contracted rates or fee schedules that Preferred Providers have agreed to accept as payment of covered services. These payments are established by CareFirst, however, in certain circumstances, the Allowed Benefit for an out-of-network provider may be established by law. When services are rendered by Non-Preferred Providers, charges in excess of the Allowed Benefit are the member’s responsibility. 4 For family coverage only: When one family member meets the individual deductible, they can start receiving benefits. Each family member cannot contribute more than the individual deductible amount. The family deductible must be met before the remaining family members can start receiving benefits. 5 For Family coverage only: When one family member meets the individual out-of-pocket maximum, their services will be covered at 100% up to the Allowed Benefit. Each family member cannot contribute more than the individual out-of-pocket maximum amount. The family out-of-pocket maximum must be met before the services for all remaining family members will be covered at 100% up to the Allowed Benefit. 6 Plan has separate out-of-pocket maximums for medical and drug expenses which accumulate independently. 7 Members who are unable to conceive have coverage for the evaluation of infertility services performed to confirm an infertility diagnosis, and some 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 create rights not given through the benefit plan. The benefits described are issued under form numbers: VA/CF/GC (R. 1/13); VA/CF/BP/EOC (7/08); VA/CF/BP/DOCS (7/08); VA/CF/BP/SOB (7/08); VA/CF/SOB-CDH (7/08); VA/CF/BLCRD (R. 1/17); VA/CF/MEM/BLCRD (R. 1/17); VA/CF/VISION (R. 1/12); VA/CF/RX3 (R. 1/18); VA/CF/ATTC (R. 1/10) and any amendments.
7
HealthyBlue 2.0
In-Network You Pay 1
Out-of-Network You Pay 1
Services
Visit www.carefirst.com/doctor to locate providers and facilities
24-HOUR NURSE ADVICE LINE
Free advice from a registered nurse. Visit www.carefirst.com/needcare to learn more about your options for care.
When your doctor is not available, call 800-535-9700 to speak with a registered nurse about your health questions and treatment options.
WELLNESS PROGRAM & BLUE REWARDS
Visit www.carefirst.com/myaccount for more information.
You have access to a comprehensive wellness program as part of your medical plan. You also have Blue Rewards, an incentive program where you can get rewarded for completing certain activities.
ANNUAL DEDUCTIBLE (Benefit period) 2
Individual
$500
$1,500
Family
$1,000
$3,000
ANNUAL OUT-OF-POCKET MAXIMUM (Benefit period) 3
Medical 4
$4,500 Individual/$6,550 Family
$6,000 Individual/$12,000 Family
Prescription Drug 4
Combined with in-network out-of-pocket maximum
All drug costs are subject to in-network out-of-pocket maximum
PREVENTIVE SERVICES
Well-Child Care (including exams & immunizations)
No charge*
No charge* after deductible
No charge*
No charge* after deductible
Adult Physical Examination (including routine GYN visit)
Breast Cancer Screening
No charge*
$50 per visit
Pap Test
No charge*
No charge* after deductible
Prostate Cancer Screening
No charge*
Deductible, then $50 per visit
Colorectal Cancer Screening
No charge*
Deductible, then $50 per visit
PCP AND SPECIALIST SERVICES
FACILITY CHARGE 5 — In addition to the physician copays/coinsurances listed below, if a service is rendered on a hospital campus, ADD facility charge if applicable
$200 per visit
Deductible, then $500 per visit
Office Visits for Illness — PCP 5,6
No charge*
Deductible, then $50 per visit
No charge*
Deductible, then $50 per visit
Convenience Care (retail health clinics such as CVS MinuteClinic or Walgreens Healthcare Clinic)
Office Visits for Illness — Specialist 5,6
$30 per visit
Deductible, then $50 per visit
Allergy Testing 5
No charge* PCP/$30 Specialist per visit
Deductible, then $50 per visit
Allergy Shots 5
No charge* PCP/$30 Specialist per visit
Deductible, then $50 per visit
Physical, Speech, and Occupational Therapy 5,7 (limited to 30 visits/injury/benefit period)
$30 per visit
Deductible, then $50 per visit
Chiropractic Services 5 (limited to 20 visits/benefit period) Acupuncture 5 (limited to 20 visits/benefit period)
$30 per visit
Deductible, then $50 per visit
$30 per visit
Deductible, then $50 per visit
EMERGENCY SERVICES
Urgent Care Center 8 (such as Patient First or Express Care)
$50 per visit
$50 per visit
Hospital Emergency Room Services 8
■ Facility
Deductible, then $200 per visit (waived if admitted)
In-network deductible, then $200 per visit (waived if admitted)
■ Physician
No charge* after deductible
No charge* after in-network deductible
8
Ambulance 8 (if medically necessary)
$50 per service
$50 per service
HealthyBlue 2.0
HealthyBlue 2.0 Summary of Benefits
In-Network You Pay 1
Out-of-Network You Pay 1
Services
DIAGNOSTIC SERVICES
Labs 9
■ Non-Hospital/Freestanding Facility
No charge*
Deductible, then $50 per visit
■ Hospital
Deductible, then $100 per visit
Deductible, then $200 per visit
X-ray 9
■ Non-Hospital/Freestanding Facility
$50 per visit
Deductible, then $50 per visit
■ Hospital
Deductible, then $150 per visit
Deductible, then $200 per visit
Imaging 9
■ Non-Hospital/Freestanding Facility
$100 per visit
Deductible, then $200 per visit
■ Hospital
Deductible, then $200 per visit
Deductible, then $500 per visit
HOSPITALIZATION — (Members are responsible for both physician and facility fees)
Outpatient Surgical Center Services
■ Facility
$100 per visit
Deductible, then $500 per visit
■ Physician
$30 per visit
Deductible, then $50 per visit
Outpatient Hospital Surgical Services
■ Facility
Deductible, then $300 per visit
Deductible, then $500 per visit
■ Physician
Deductible, then $30 per visit
Deductible, then $50 per visit
Inpatient Hospital Services
■ Facility
Deductible, then $300 per day ($1,500 maximum per admission)
Deductible, then $500 per day ($2,500 maximum per admission)
■ Physician
Deductible, then $30 per visit
Deductible, then $50 per visit
HOSPITAL ALTERNATIVES
Home Health Care
Deductible, then $30 per visit
Deductible, then $50 per visit
Hospice (Inpatient — limited to 30 days; Outpatient — unlimited during Hospice eligibilityperiod)
Deductible, then $30 per visit
Deductible, then $50 per visit
Skilled Nursing Facility (limited to 60 days/benefit period)
Deductible, then $30 per admission
Deductible, then $50 per admission
MATERNITY
Preventive Prenatal and Postnatal Office Visits No charge*
Deductible, then $50 per visit
Delivery and Facility Services
Deductible, then $300 per day ($1,500 maximum per admission)
Deductible, then $500 per day ($2,500 maximum per admission)
Artificial and Intrauterine Insemination 5,10
Not covered
Not covered
In Vitro Fertilization Procedures 5,10
Not covered
Not covered
MENTAL HEALTH AND SUBSTANCE USE DISORDER — (Members are responsible for both physician and facility fees)
Office Visits
No charge*
Deductible, then $50 per visit
Outpatient Services
■ Facility
No charge*
Deductible, then $50 per visit
■ Physician
No charge*
Deductible, then $50 per visit
Inpatient Services
■ Facility
Deductible, then $300 per day ($1,500 maximum per admission)
Deductible, then $500 per day ($2,500 maximum per admission)
■ Physician
Deductible, then $30 per visit
Deductible, then $50 per visit
MEDICAL DEVICES AND SUPPLIES
Durable Medical Equipment
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Hearing Aids
Not covered
Not covered
VISION
Routine Exam (limited to 1 visit/benefit period) $10 per visit at participating vision provider
Total charge minus $33 Allowed Benefit
Eyeglasses and Contact Lenses
Not covered
Discounts from participating vision centers
9
HealthyBlue 2.0
HealthyBlue 2.0 Summary of Benefits
Note: Allowed Benefit is the fee that participating, in-network providers have agreed to accept for a particular covered service. The provider 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 (if applicable) and CareFirst will pay the remaining amount up to $50.
No copayment or coinsurance.
1 When multiple services are rendered on the same day by more than one provider, Member payments are required for each provider. 2 For family coverage only: The family deductible must be met before any member starts receiving benefits. The deductible may be met by one member or any combination of members. 3 For Family coverage only: The family out-of- pocket maximum must be met before any member’s services will be covered at 100% up to the Allowed Benefit. The out-of-pocket maximum may be met by one member or any combination of members. 4 Plan has an integrated medical and prescription drug out-of-pocket maximum. 5 If 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 a telemedicine service. 7 There are no limits for children under age 19 when Physical, Speech or Occupational Therapy is included as part of Habilitative Services. 8 If 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. 9 Members accessing laboratory services inside the CareFirst Service area (Maryland, D.C., Northern Virginia) must use LabCorp as their Lab Test facility and a non-hospital/freestanding facility for X-rays and specialty Imaging for In-Network benefits. Services performed by any other provider, while inside the CareFirst Service area will be considered Out-of-Network. Members accessing laboratory, X-rays, and specialty Imaging services outside of Maryland, D.C. or Northern Virginia, may use any participating BlueCard PPO facility and receive out-of-network benefits. 10 Members who are unable to conceive have coverage for the evaluation of infertility services performed to confirm an infertility diagnosis, and some 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 create rights not given through the benefit plan. The benefits described are issued under form numbers: VA/CFBC/GC (R. 1/13); VA/CFBC/HB2/EOC (R. 10/11); VA/CFBC/DOL APPEAL (R. 7/12); VA/CFBC/LG/POS/DOCS (6/16); VA/CFBC/LG/POS/SOB (6/16); VA/CFBC/LG/INCENT (R. 1/18); VA/CFBC/RX3 (R. 1/18); VA/CFBC/ATTC (R. 1/10); VA/CFBC/LG/CCHRADM (R. 1/19); VA/CFBC/LG/INCENT (R. 1/19); VA/CFBC/LG/2019 AMEND (R. 1/19); VA/CFBC/LG/GC AMEND (R. 1/19) and any amendments.
10
Additional Medical Services
BLUE REWARDS Earning your rewards just got easier! With our improved Blue Rewards incentive program, you can decide which healthy activities interest you and be rewarded for completing them. How it works Blue Rewards offers you incentives for taking steps to get and stay healthy. Both you and your partner can earn rewards for completing one or all of the following activities:
Earn $ 100
Earn $ 50
Earn $ 25
LEARN MORE ABOUT THE ACTIVITIES
Choosing a PCP Be sure to choose a PCP* who participates in our Patient-Centered Medical Home (PCMH) program to earn your reward. The PCMH program is designed to provide your PCP with a more complete view of your health needs and the care you receive from other providers.
RealAge Developed by our trusted partner, Sharecare Inc.,** the RealAge test is a confidential online health assessment that helps determine the physical age of your body compared to your calendar age. RealAge identifies habits impacting your body’s age so you can improve your well-being.
Health screening Health screenings help you understand your current health status, so you can take steps to improve it. You can complete a health screening with your PCP or at a CVS MinuteClinic.
Your CareFirst Blue Rewards Visa® Incentive Card After you complete one or more of the activities, you’ll receive your incentive card in about 10-14 days. The incentive card can be used toward your annual deductible or other out-of-pocket costs like copays or coinsurance related to eligible expenses (medical, prescription drug, dental and vision) under your CareFirst BlueCross BlueShield (CareFirst) health plan. Make sure to always save your receipts as proof of your expense.
JOIN BLUE365 & START SAVING TODAY! Blue365 gives you access to savings across all aspects of your life – including 20 percent off on Fitbit devices and over $800 off Lasik, discounts on healthy, organic meal delivery services like Sun Basket, and much more! Register now for free to take advantage of Blue365. It’s an online destination where participating members can find healthy deals and exclusive discounts, all you need is your
Keep the card as long as you are a CareFirst member as any future incentives you earn will be automatically added to the same card. You have until the end of your benefit period to use your reward, plus an additional 90 days to reimburse yourself for any eligible expense that occurred within that benefit period. Note: only one card is issued to the policyholder, but it can be used by everyone covered under your policy (including dependent children). To get started, visit carefirst.com/sharecare. You’ll need to enter your CareFirst account username and password and complete the one-time registration with Sharecare to link your CareFirst account information. This will help personalize your experience. Blue Cross and Blue Shield member card to get started. Get started today at www.Blue365Deals.com/register
11
Additional Medical Services
CAREFIRST MY ACCOUNT As a CareFirst BlueCross BlueShield (CareFirst) member, your personalized benefit information is available 24/7. Register for My Account for secure online access to your coverage details, ID cards and more. Plus, you’ll also be able to quickly locate in -network providers and facilities nationwide. Go to carefirst.com/myaccount to register. CAREFIRST MOBILE APP Once you register with My Account you can download the CareFirst Mobile app to access in-network doctors, urgent care centers and other care nationwide. You can also view, order, or email member ID Cards, Check claims and Deductible status, Update communication preferences, Plus more. Visit your favorite online store to download the CareFirst app. KNOW BEFORE YOU GO Choosing the right setting for your care — from allergies to X-rays — is key to getting the best treatment with the lowest out-of-pocket costs. It’s important to understand your options so you can make the best decision when you or your family members need care. Primary care provider (PCP)
Convenience care centers (retail health clinics) These are typically located inside a pharmacy or retail store (like CVS MinuteClinic or Walgreens Healthcare Clinic) and offer accessible care with extended hours. Visit a convenience care center for help with minor concerns like cold symptoms and ear infections. Urgent care centers Urgent care centers (such as Patient First or ExpressCare) have a doctor on staff and are another option when you need care on weekends or after hours. Emergency room (ER) An emergency room provides treatment for acute illnesses and trauma. You should call 911 or go straight to the ER if you have a life-threatening injury, illness or emergency. Prior authorization is not needed for emergency room services
Establishing a relationship with a primary care provider is the best way to receive consistent, quality care. Except for emergencies, your PCP should be your first call when you require medical attention. Your PCP may be able to provide advice over the phone or fit you in for a visit right away. FirstHelp — free 24-hour nurse advice line Call 800-535-9700 anytime to speak with a registered nurse. Nurses will discuss your symptoms with you and recommend the most appropriate care. CareFirst Video Visit See a doctor 24/7/365 without an appointment! You can consult with a board-certified doctor on your smartphone, tablet or computer. Doctors can treat a number of common health issues like flu and pink eye. Visit carefirstvideovisit.com for more information. WHEN YOU NEED CARE
When your PCP isn’t available, being familiar with your options will help you locate the most appropriate and cost-effective medical care. The chart below shows how costs* may vary for a sample health plan depending on where you choose to get care.
To determine your specific benefits and associated costs: • Log in to My Account at carefirst.com/myaccount • Check your Evidence of Coverage or benefit summary • Ask your benefit administrator, or • Call Member Services at the telephone number on the back of your member ID card
Sample cost Sample symptoms 24/7 Rx
Cough, cold and flu Pink eye Ear pain Cough, cold and flu Pink eye Ear pain Sprains Cut requiring stitches Minor burns Chest pain Difficulty breathing Abdominal pain
Video Visit
$20
Convenience Care (e.g., CVS MinuteClinic or Walgreens Healthcare Clinic)
$20
Urgent Care (e.g., Patient First or ExpressCare)
$60
Emergency Room
$200
The costs in this chart are for illustrative purposes only and may not represent your specific benefits or costs.
12
Pharmacy Program Summary of Benefits
Formulary 3 ■ 5-Tier ■ $0 Deductible ■ $10/25/45 ■ Specialty 50%/50%
Plan Feature
Amount You Pay
Description
Your benefit does not have a deductible.
None
Individual Deductible
Your benefit does not have a family deductible.
None
Family Deductible
See medical summary of benefits for annual out‑of‑pocket amount
If you reach your out‑of‑pocket maximum, CareFirst or CareFirst BlueChoice will pay 100% of the applicable allowed benefit for most covered services for the remainder of the year. All deductibles, copays, coinsurance and other eligible out‑of‑pocket costs count toward your out‑of‑pocket maximum, except balance billed amounts. A preventive drug is a prescribed medication or item on CareFirst’s Preventive Drug List.* Diabetic supplies include needles, lancets, test strips and alcohol swabs.
Out-of-Pocket Maximum
Preventive Drugs (up to a 34‑day supply) Oral Chemotherapy Drugs and Diabetic Supplies (up to a 34‑day supply) Generic Drugs (Tier 1) (up to a 34‑day supply) Preferred Brand Drugs (Tier 2) (up to a 34‑day supply) Non-preferred Brand Drugs (Tier 3) (up to a 34‑day supply) Preferred Specialty Drugs (Tier 4) (up to a 34‑day supply) Non-preferred Specialty Drugs (Tier 5) (up to a 34‑day supply)
$0
$0
Generic drugs are covered at this copay level.
$10
All preferred brand drugs are covered at this copay level.
$25
All non‑preferred brand drugs on this copay level are not on the Preferred Drug List.* Discuss using alternatives with your physician or pharmacist.
$45
50% up to a $100 maximum You pay 50% coinsurance up to a maximum of $100 for all preferred specialty drugs. Benefits for covered Specialty drugs are available when purchased by mail order. 50% up to a $150 maximum You pay 50% coinsurance up to a maximum of $150 for all non‑ preferred specialty drugs. Benefits for covered Specialty drugs are available when purchased by mail order.
Generic: $20 Preferred Brand: $50
Maintenance Drugs (up to a 90‑day supply)
Maintenance generic, preferred brand and non‑preferred brand drugs up to a 90‑day supply are available for twice the copay through Mail Service Pharmacy or a retail pharmacy. Maintenance preferred and non‑preferred specialty drugs up to a 90‑day supply you pay 50% coinsurance up to a maximum copay. Benefits for covered Specialty drugs are available when purchased by mail order.
Non‑preferred Brand: $90 Preferred Specialty: 50% up to a $200 maximum Non‑preferred Specialty: 50% up to a $300 maximum
If a provider prescribes a non‑preferred brand drug when a generic is available, you will pay the non‑preferred brand copay or coinsurance PLUS the cost difference between the generic and brand drug up to the cost of the prescription. If a generic version is not available, you will only pay the copay or coinsurance. Also, if your prescription is written for a brand‑name drug and DAW (dispense as written) is noted by your doctor, you will only pay the copay or coinsurance.
Restricted Generic Substitution
Visit carefirst.com/rx for the most up-to-date drug lists, including the prescription guidelines. Prescription guidelines indicate drugs that require your doctor to obtain prior authorization from CareFirst before they can be filled and drugs that can be filled in limited quantities.
This plan summary is for comparison purposes only and does not create rights not given through the benefit plan. Policy Form Numbers: VA/CFBC/RX3 (R. 1/18) • VA/CF/RX3 (R. 1/18)
13
AnAn IntrIntroducoductiontion toto FSAs A flexible spending account (FSA) is a personal expense account that lets you set aside a portion of your salary pretax and use that money to pay for medical costs not paid for by your health plan. An Introduction to FSAs
How it works
• You enroll in your employer-sponsored FSA
• You elect a contribution amount for the year. Contribute only what you think you'll need, because any money left at the end of the year does not roll over unless your employer allows FSA rollover or a grace period. • Contributions are deducted in equal installments throughout the year from your paycheck, so there’s no extra work on your part. The deductions are made pretax, so they should ultimately reduce your tax bill. • Throughout the year, you can use the money in your FSA to pay for health expenses--these will count toward your health plan deductible and out-of-pocket maximum.
How much should you contribute?
When deciding how much to contribute to your FSA, consider the following questions:
• Do you expect to have medical, dental, or vision expenses that are not fully covered by insurance?
• Do you, your spouse, or your eligible tax dependents have an ongoing condition that requires expensive medication or frequent visits to a physician? • Do you, your spouse or eligible dependents need prescription eyeglasses, sunglasses, contact lenses and/or lens solution?
• Do you pay for day care for your children or adult dependents?
Remember, be conservative in your estimates because money left in the account at the end of the year may be forfeited unless your employer allows FSA rollover or a grace period.
Additional resource
You can use our worksheet to calculate how much money you should set aside.
14
Further Flexible Spending Account
FSA The Medical Flexible Spending Account Welcome to your flexible spending account (FSA) from Further. We’re one of the largest, most experienced and trusted FSA administration partners in the nation. Everything you need is just a tap, click, call or swipe away. If you have questions about an FSA, our expert team is ready to help.
How a medical FSA works
Decide how much you may pay for medical, dental and vision costs next year. (Plan wisely. Depending on the plan your employer sets up, any unused money may be forfeited at the end of the plan year or grace period.) The amount you select is withheld pretax from your pay in equal portions throughout the year and put into your FSA. Your total FSA contribution is available from day one, even if it has not all been deposited into your account. Pay your out-of-pocket medical bills using a Further Visa® Debit Card or by submitting receipts for reimbursement. 2
Introducing the FSA A flexible spending account (FSA) is a personal expense account that works with your health plan. Each year you can set aside a portion of your salary pretax. You can use that money to pay for medical costs not paid for by your health plan. Depending on your tax bracket, an FSA can help you save as much as 10 to 40 percent on most of these costs. 1
1 See your tax advisor with questions.
15
Further Flexible Spending Account
Pay for health care expenses tax-free
All systems go! Use your FSA for these:
■ Medical expenses that your plan doesn’t cover: – Out-of-pocket expenses until you reach your deductible
Select a medical FSA at
– Copayments, coinsurance and prescription drugs
■ Dental and vision care not covered by your health plan
Heads up! You can’t use your FSA for these:
■ Health insurance monthly premiums
We’re here for you Talk with one of our specially trained FSA customer service representatives to answer any questions you may have.
■ Expenses that aren’t related to medical treatment or care as defined by the IRS
It’s important to save all your receipts and explanation of benefits (EOB) statements to validate expenses, as required by the IRS.
1-800-859-2144
7 a.m. to 8 p.m. CST, Monday-Friday
hellofurther.com
16
Dental Benefits
Metropolitan Life Insurance Company
Overview of Benefits for: ALFRED STREET BAPTIST CHURCH The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefits for a wide range of covered services — both in and out of the network. The goal is to deliver affordable protection for a healthier smile and a healthier you.
In-Network: % of Negotiated Fee
Out-of-Network: % of R&C Fee 1
Coverage Type
Type A
100%
100%
Type B
100%
80%
Type C
60%
50%
Orthodontia
50%
50%
Deductible: Individual/Family*
$50 (Type B & C)
$50 (Type B & C)
Annual Maximum Benefit: Per Individual
$3000
$3000
$1500
$1500
Orthodontia Lifetime Maximum: Per Individual
Ortho applies to Child Only (up to age 19)
Understanding Your Dental Benefits Plan
Take advantage of online self-
With the MetLife Preferred Dentist Program you can visit the dentist of your choice – an “in - network” dentist (a participating MetLife dentist) or an “out -of- network” dentist. • Plan benefits for in-network services are based on the percentage of the Negotiated fee – the fee that in-network dentists have agreed to accept as payment in full for covered services, subject to any co-payments, deductibles, cost sharing and benefit maximums. Negotiated fees are subject to change. • Plan benefits for out-of-network services are based on a percentage of the Reasonable and Customary (R&C) charge. If you choose a dentist who does not participate in the network, your out-of-pocket expenses may be higher, since you will be responsible for paying any difference between the dentist's fee and your plan's payment for the approved service. Please refer to the Selected Covered Services and Frequency Limitations page of this document for details regarding how R&C charges are defined under this plan.
Locate a participating dentist Access MetLife’s Oral Health Library
go to www.metlife.com/mybenefits
Certain plan benefits are based on a percentage of the negotiated fee. This is the amount that participating dentists have agreed to accept as payment in full. If your plan benefits are based on a percentage of the Reasonable and Customary (R&C) charges, your out-of-pocket expenses may be more, since you will be responsible for paying any difference between the dentist's fee and your plan's payment for the approved service.
17
Dental Benefits cont .
Selected Covered Services and Frequency Limitations*
Type A •
Oral Examinations
1 in 6 months.
Cleanings
1 in 6 months.
•
Fluoride
Children to age 14 / 1 in 12 months.
•
Bitewing X-rays
Adult - 1 in 12 months / Children - 1 in 12 months.
•
Type B •
Full Mouth X-rays
1 in 60 months.
Periodontal Maintenance
2 in 1 year less the number of teeth cleanings.
•
For dependent children to age 14. Limited to 1 per lifetime per area.
Space Maintainers
•
Emergency Palliative Treatment
•
1 per tooth in 60 months of a dependent child up to 14 th birthday.
Sealants (1st & 2nd permanent molars)
•
Amalgam & Composite Fillings
1 per surface in 24 months.
•
Type C •
Crowns
1 in 10 years.
Dentures
1 in 10 years.
•
Bridges
1 in 10 years.
•
Periodontal Root Planning & Scaling
1 per quadrant in any 24 months period.
•
Periodontal Surgery
1 in 36 months.
•
Simple Extractions
•
Root Canal
One per tooth per Lifetime.
•
Surgical Extractions
•
Repairs (Crowns)
1 in 12 months.
•
Implants
1 in 10 years.
•
Orthodontia • Dependent children are covered up to their 19th birthday.
• All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.
Payments are on a repetitive basis.
•
• 20% of the Orthodontia Lifetime Maximum will be considered at initial placement of the appliance and paid based on the plan benefit’s coinsurance level for Orthodontia as defined in the Plan Summary.
• Orthodontic benefits end at cancellation of coverage.
The service categories and plan limitations shown in this document represent an overview of your plan benefits, but are not a complete description of the plan. Before making any purchase or enrollment decision you should review the certificate of insurance which is available through MetLife or your employer. In the event of a conflict between this overview and your certificate of insurance, your certificate of insurance governs. Like most group dental insurance policies, MetLife group policies contain certain exclusions, limitations and waiting periods and terms for keeping them in force. The certificate of insurance sets forth all plan terms and provisions, including all exclusions and limitations. *Alternate Benefits: Your dental plan provides that if there are two or more professionally acceptable dental treatment alternatives for a dental condition, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we suggest you discuss treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plan’s reimbursement for those services, and your out-of-pocket expense. Actual
18
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28Made with FlippingBook - Online magazine maker