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.
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