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BluePreferred PPO Gold 1000 Summary of Benefits
Note: Allowed Benefit is the fee that providers in the network have agreed to accept for a particular service. The 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 deductible (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- and out-of-network deductible and out-of-pocket maximums do not contribute to each other.
3 Separate - 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.
4 Separate - 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.
The out-of-pocket maximum includes deductibles, copays and coinsurance.
5 All drug costs are subject to the in-network out-of-pocket maximum.
6 If a service is rendered on a hospital campus you could receive two bills, one from the physician and one from the facility.
7 “Telemedicine services” refers to the use of a combination of interactive audio, video, or other electronic media used for the purpose of diagnosis,
consultation, or treatment. Use of audio-only telephone, electronic mail message (e-mail), or facsimile transmission (FAX) is not considered a
telemedicine service.
8 If the out-of-network benefit is listed as contributing toward the in-network deductible, then it also contributes toward the in-network out-of-pocket
maximum.
9 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.
10 Except for emergency services or out-of-area urgent care, if a member goes to a non-participating pharmacy, the member is responsible for
the copay/coinsurance for the drug plus the difference between the allowed charge and the actual charge for that drug (called balance billed
amount). The balance billed amount does not contribute to the out-of-pocket maximum.
11 Benefits for Specialty Drugs are only available when Specialty Drugs are purchased from and dispensed by a specialty Pharmacy in the Exclusive
Specialty Pharmacy Network.
12 If a Generic drug becomes available for a Preferred Brand drug, the Preferred Brand drug moves to the Non-preferred Brand drug tier.
13 If a provider prescribes a Non-preferred Brand drug, and the Member selects the Non-preferred Brand drug when a Generic drug is available,
the Member shall pay the applicable Copayment or Coinsurance as stated in the Schedule of Benefits plus the difference between the price of
the Non-preferred Brand drug and the Generic drug up to the cost of the drug. This amount will not contribute to the Out-of-Pocket Maximum.
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: MD/CF/GC (1/14); MD/CF/SG/2019 GC AMEND (1/19); MD/CF/SG/PPO/EOC (R. 1/21);
MD/GHMSI/DOL APPEAL (R. 9/11); MD/CF/SHOP/PPO DOCS (R. 1/17); MD/CF/SHOP/BP PPO CDH/BRZ 6200 (1/21); MD/CF/SHOP/BP PPO CDH/SIL
2400 (1/21); MD/CF/SHOP/BP PPO/GOLD 1000 (1/21); MD/CF/SG/BP PPO CDH/SIL 1500 (1/21); MD/CF/SG/BP PPO CDH/SIL 2000 (1/21); MD/CF/SG/BP
PPO CDH/SIL 2100 70 (1/21); MD/CF/SG/BP PPO/GOLD 500 (1/21); MD/CF/SG/BP PPO/GOLD 1000 (1/21); MD/CF/SG/BP PPO/GOLD 1500 (1/21);
MD/CF/SG/BP PPO/PLAT 0 (1/21); MD/CF/SG/BP PPO/PLAT 500 (1/21); MD/CF/SG/BP PPO/SIL 1500 (1/21); MD/CF/BLUECARD (5/12); MD/CF/MEM/BLCRD
(1/12); MD/CF/ANCILLARY AMEND (10/12); MD/CF/SG/ELIG AMEND (1/17); MD/CF/SG/2021 AMEND (1/21); MD/CF/SG/PPO/AUTH AMEND (1/20);
MD/CF/GRP/FAM PLAN (1/20); GHMSI – DISCLOSURE 10/15; MD NCA-HEALTH GUARANTY 10/12; MD/CF/SG/PPO/INCENT (R. 1/21);
MD/CF/SHOP/PARTNER (1/14); MD/PT PROTECT (9/10); MD/CF/ELIG (1/14) and any amendments. CFMI/GC (1/14); CFMI/SG/2019 GC AMEND (1/19);
CFMI/SG/PPO/EOC (R. 1/21); CFMI/DOL APPEAL (R. 9/11); CFMI/SHOP/PPO DOCS (R. 1/17); CFMI/SHOP/BP PPO CDH/BRZ 6200 (1/21); CFMI/SHOP/BP
PPO CDH/SIL 2400 (1/21); CFMI/SHOP/BP PPO/GOLD 1000 (1/21); CFMI/SG/BP PPO CDH/SIL 1500 (1/21); CFMI/SG/BP PPO CDH/SIL 2000 (1/21);
CFMI/SG/BP PPO CDH/SIL 2100 70 (1/21); CFMI/SG/BP PPO/GOLD 500 (1/21); CFMI/SG/BP PPO/GOLD 1000 (1/21); CFMI/SG/BP PPO/GOLD 1500
(1/21); CFMI/SG/BP PPO/PLAT 0 (1/21); CFMI/SG/BP PPO/PLAT 500 (1/21); CFMI/SG/BP PPO/SIL 1500 (1/21); CFMI/BLUECARD (5/12);
CFMI/BLUECARD-MEMBER (1/12); MD/CFMI/ANCILLARY AMEND (10/12); CFMI/SG/ELIG AMEND (1/17); CFMI/SG/2021 AMEND (1/21);
CFMI/SG/PPO/AUTH AMEND (1/20); CFMI/GRP/FAM PLAN (1/20); CFMI-DISCLOSURE 10/15; CF-HEALTH GUARANTY 10/12; CFMI/SG/PPO/INCENT
(R. 1/21); CFMI/SHOP/PARTNER (1/14); MD/PT PROTECT (9/10); CFMI/ELIG (1/14) and any amendments.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc., which are independent licensees of
the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans.
SUM5170-1P (1/21) ■ MD ■ 2021 2-50 ACA Compliant (Can be sold as HRA)
