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
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