Page 17 - NAPA 2021-2022

BluePreferred PPO Gold 1000 Summary of Benefits

Services In-Network You Pay 1 Out-of-Network You Pay 1
PRESCRIPTION DRUGS 10,11​
Formulary List​ Visit www.carefirst.com/acarx to locate Formulary List​
Annual Prescription Drug Deductible​ $250 per person​
(waived for generic drugs; preferred and non-preferred brand insulin)​
Preventive Drugs​ No charge*​
Diabetic Supplies, Oral Chemo Drugs and​ No charge*​
Medication Assisted Treatment Drugs​
Generic Drugs​ 30-day supply $10; 90-day supply $20 (maintenance drugs only)​
12
Preferred Brand Drugs (Preferred Insulin $0)​ 30-day supply Deductible, then $45;​
90-day supply Deductible, then $90 (maintenance drugs only)​
13
Non-preferred Brand Drugs (Non-preferred​ 30-day supply Deductible, then $65;​
Insulin capped at $50 for 30 days/$100 for 90​ 90-day supply Deductible, then $130 (maintenance drugs only)​
days)​
Preferred Specialty Drugs (must be filled​ 30-day supply Deductible, then 50% up to $100 maximum;​
through Exclusive Specialty Pharmacy Network)​ 90-day supply Deductible, then 50% up to $200 maximum (maintenance drugs only)​
Non-Preferred Specialty Drugs (must be filled​ 30-day supply Deductible, then 50% up to $150 maximum;​
through Exclusive Specialty Pharmacy Network)​ 90-day supply Deductible, then 50% up to $300 maximum (maintenance drugs only)​
PEDIATRIC VISION—(Through the end of the calendar year in which the dependent turns 19)​
Routine Exam (limited to 1 visit/benefit period)​ No charge*​ Total charge minus $40 reimbursement​
Frames and Contact Lenses—Pediatric​ No charge*​ Reimbursements apply​
Collection Only​
Spectacle Lenses​ No charge*​ Reimbursements apply​
PEDIATRIC DENTAL—(Through the end of the calendar year in which the dependent turns 19)​
Annual Dental Deductible​ $25​ $50​
Class I Preventative & Diagnostic Services—​ No charge*​ 20% of Allowed Benefit​
Exams (2 per year). Cleanings (2 per year),​
fluoride treatments (2 per year), sealants,​
bitewing X-rays (2 per year), full mouth X-ray​
(one every 3 years)​
Class II Basic Services—Fillings (amalgam or​ Deductible, then 20% of Allowed Benefit​ Deductible, then 40% of Allowed Benefit​
composite), simple extractions, non-surgical​
periodontics​
Class III Major Services—Surgical periodontics,​ Deductible, then 20% of Allowed Benefit​ Deductible, then 40% of Allowed Benefit​
endodontics, oral surgery​
Class IV Major Services—Restorative Crowns,​ Deductible, then 50% of Allowed Benefit​ Deductible, then 65% of Allowed Benefit​
dentures, inlays and onlays​
Class V Medically Necessary Orthodontic​ 50% of Allowed Benefit​ 65% of Allowed Benefit​
Services​

SUM5170-1P (1/21) ■ MD ■ 2021 2-50 ACA Compliant (Can be sold as HRA)​