HealthyBlue 2.0
In-Network You Pay 1
Out-of-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
$500
$1,500
Family
$1,000
$3,000
ANNUAL OUT-OF-POCKET MAXIMUM (Benefit period) 3
Medical 4
$4,500 Individual/$6,550 Family
$6,000 Individual/$12,000 Family
Prescription Drug 4
Combined with in-network out-of-pocket maximum
All drug costs are subject to in-network out-of-pocket maximum
PREVENTIVE SERVICES
Well-Child Care (including exams & immunizations)
No charge*
No charge* after deductible
No charge*
No charge* after deductible
Adult Physical Examination (including routine GYN visit)
Breast Cancer Screening
No charge*
$50 per visit
Pap Test
No charge*
No charge* after deductible
Prostate Cancer Screening
No charge*
Deductible, then $50 per visit
Colorectal Cancer Screening
No charge*
Deductible, then $50 per visit
PCP AND SPECIALIST SERVICES
FACILITY CHARGE 5 — In addition to the physician copays/coinsurances listed below, if a service is rendered on a hospital campus, ADD facility charge if applicable
$200 per visit
Deductible, then $500 per visit
Office Visits for Illness — PCP 5,6
No charge*
Deductible, then $50 per visit
No charge*
Deductible, then $50 per visit
Convenience Care (retail health clinics such as CVS MinuteClinic or Walgreens Healthcare Clinic)
Office Visits for Illness — Specialist 5,6
$30 per visit
Deductible, then $50 per visit
Allergy Testing 5
No charge* PCP/$30 Specialist per visit
Deductible, then $50 per visit
Allergy Shots 5
No charge* PCP/$30 Specialist per visit
Deductible, then $50 per visit
Physical, Speech, and Occupational Therapy 5,7 (limited to 30 visits/injury/benefit period)
$30 per visit
Deductible, then $50 per visit
Chiropractic Services 5 (limited to 20 visits/benefit period) Acupuncture 5 (limited to 20 visits/benefit period)
$30 per visit
Deductible, then $50 per visit
$30 per visit
Deductible, then $50 per visit
EMERGENCY SERVICES
Urgent Care Center 8 (such as Patient First or Express Care)
$50 per visit
$50 per visit
Hospital Emergency Room Services 8
■ Facility
Deductible, then $200 per visit (waived if admitted)
In-network deductible, then $200 per visit (waived if admitted)
■ Physician
No charge* after deductible
No charge* after in-network deductible
8
Ambulance 8 (if medically necessary)
$50 per service
$50 per service
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