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BluePreferred PPO Gold 1000 Summary of Benefits
Non-Integrated Deductible
Services In-Network You Pay 1 Out-of-Network You Pay 1
Visit www.carefirst.com/doctor to locate providers and facilities
24-HOUR NURSE ADVICE LINE
Free advice from a registered nurse. When your doctor is not available, call 800-535-9700 to speak with a registered nurse
Visit www.carefirst.com/needcare to learn about your health questions and treatment options.
more about your options for care.
WELLNESS PROGRAM & BLUE REWARDS
Visit www.carefirst.com/sharecare for more You have access to a comprehensive wellness program as part of your medical plan.
information. You also have Blue Rewards, an incentive program where you can get rewarded for
completing certain activities.
ANNUAL MEDICAL DEDUCTIBLE (Benefit Period) 2,3
Individual/Family $1,000 Individual/$2,000 Family (separate) $2,000 Individual/$4,000 Family (separate)
ANNUAL OUT-OF-POCKET MAXIMUM (Benefit Period) 2,4,5
Individual/Family $5,750 Individual/$11,500 Family $11,500 Individual/$23,000 Family
(separate) (separate)
PREVENTIVE SERVICES
Well-Child Care No charge* No charge*
(including exams & immunizations)
Adult Physical Examination (including routine No charge* No charge* after deductible
GYN visit)
Breast Cancer Screening No charge* No charge*
Pap Test No charge* No charge* after deductible
Prostate Cancer Screening No charge* No charge*
Colorectal Cancer Screening No charge* No charge* after deductible
PCP AND SPECIALIST SERVICES
6
FACILITY CHARGE —In addition to the physician Deductible, then $50 per visit Deductible, then $150 per visit
copays/coinsurances listed below, if a service
is rendered on a hospital campus, ADD facility
charge if applicable (also applies to Artificial
Insemination and In Vitro Fertilization on page
2)
Office Visits for Illness—PCP 6,7 $15 per visit Deductible, then $50 per visit
Office Visits for Illness—Specialist 6,7 $30 per visit Deductible, then $50 per visit
Allergy Testing 6 $30 per visit Deductible, then $50 per visit
Allergy Shots 6 $30 per visit Deductible, then $50 per visit
Physical, Speech, and Occupational Therapy 6 $30 per visit Deductible, then $50 per visit
(limited to 30 visits/illness or injury/benefit
period)
Chiropractic 6 $30 per visit Deductible, then $50 per visit
(limited to 20 visits/benefit period)
Acupuncture 6 $30 per visit Deductible, then $50 per visit
IMMEDIATE AND EMERGENCY SERVICES
Convenience Care (retail health clinics such as $15 per visit Deductible, then $50 per visit
CVS MinuteClinic or Walgreens Healthcare
Clinic)
Urgent Care Center 8 $50 per visit $50 per visit
(such as Patient First or ExpressCare)
Hospital Emergency Room Services 8
■ Facility Deductible, then $250 per visit (waived if In-network deductible, then $250 per visit
admitted) (waived if admitted)
■ Physician Deductible, then $30 per visit In-network deductible, then $30 per visit
Ambulance (if medically necessary) 8 Deductible, then $30 per service In-network deductible, then $30 per
service
SUM5170-1P (1/21) ■ MD ■ 2021 2-50 ACA Compliant (Can be sold as HRA)
