Page 11 - Public Citizen 2021-2022

This plan uses a provider network. You will pay less if you use a provider in the plan’s network.

Yes. See www.carefirst.com or call You will pay the most if you use an out-of-network provider, and you might receive a bill from a
Will you pay less if you 1-855-258-6518 for a list of provider provider for the difference between the provider’s charge and what your plan pays (balance
use a network provider?
network. billing). Be aware, your network provider might use an out-of-network provider for some
services (such as lab work). Check with your provider before you get services.

Do I need a referral to see You can see the specialist you choose without a referral.

a specialist? No.

What You Will Pay

Common Services You May Need In-Network Provider Out-of-Network Provider Limitations, Exceptions & Other

Medical Event (You will pay the least) (You will pay the most) Important Information
If a service is rendered at a Hospital
Primary care visit to treat an $10 copay per visit Deductible, then 20% of Facility, the additional Facility charge may

injury or illness Allowed Benefit
apply

If a service is rendered at a Hospital
Deductible, then 20% of
If you visit a health Specialist visit $10 copay per visit Allowed Benefit Facility, the additional Facility charge may
care provider’s office or apply
clinic Deductible, then 20% of
Retail Health Clinic $10 copay per visit None
Allowed Benefit

Preventive care/screening/ No Charge Deductible, then 20% of Some services may have limitations or

immunization Allowed Benefit exclusions based on your contract

LabTest: Non-Hospital:
LabTest: Non-Hospital: Deductible, then 20% of

Diagnostic test (x-ray, blood No Charge Allowed Benefit If a service is rendered at a Hospital
Facility, the additional Facility charge may
work) XRay: Non-Hospital: No XRay: Non-Hospital: apply. Please see your contract.
Charge Deductible, then 20% of

If you have a test Allowed Benefit

If a service is rendered at a Hospital
Non-Hospital: No Non-Hospital: Deductible,
Imaging (CT/PET scans, MRIs) Facility, the additional Facility charge may
Charge then 20% of Allowed Benefit
apply. Please see your contract.

For all prescription drugs:
Generic drugs $8 copay Paid As In-Network
Prior authorization may be required for

SBC ID: SBC20210607MANBPPDBL01RXXDB755N072021 Page 2 of 7