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
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