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.
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