Page 9 - Public Citizen 2021-2022

Summary of Benefits and Coverage: What This Plan Covers & What You Pay for Covered Services

BluePreferred Option 1 Coverage Period: 07/01/2021 - 06/30/2022

Coverage for: Individual | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible , provider,
or other underlined terms see the Glossary. You can see the Glossary at www.carefirst.com/sbcg or call 1-855-258-6518 to request a copy. For more information about your
coverage, or to get a copy of the complete terms of coverage, please visit http://content.carefirst.com/sbc/contracts/BPPDBL01RXXDB755.pdf.

Important Questions Answers Why this Matters:

Generally, you must pay all the costs from provider up to the deductible amount before this
plan begins to pay. If you have other family member(s) on the plan, each family member may
What is the overall In-Network: $0; Out-of-Network: need to meet their own individual deductible, OR all family members may combine to meet the
deductible? $300 individual/ $600 family.
overall family deductible before the plan begins to pay, depending upon plan coverage. Please
refer to your contract for further details.

This plan covers some items and services even if you haven’t yet met the deductible amount.
Are there services Yes, all In-Network services are But, a copayment or coinsurance may apply. For example, this plan covers certain preventive
covered before you meet provided without a deductible. services without cost sharing and before you meet your deductible. See a list of covered
your deductible ?
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services.

services?

The out-of-pocket limit is the most you could pay in a plan year for covered services. If you
Medical: In-Network: $1,000 have other family member(s) on the plan, each family member may need to meet their own
What is the out-of-pocket individual/ $2,000 family; out-of-pocket limits, OR all family members may combine to meet the overall family

limit for this plan? Out-of-Network: $2,000 individual/ out-of-pocket limit, depending upon plan coverage. Please refer to your contract for further
$4,000 family.
details.

Premiums, balance-billed charges,
What is not included in and health care this plan does not Even though you pay these expenses, they don't count toward the out-of-pocket limit.
the out-of-pocket limit?
cover.

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. ® Registered trademark of the Blue Cross and Blue Shield Association.
SBC ID: SBC20210607MANBPPDBL01RXXDB755N072021 Page 1 of 7