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.
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