Page 18 - The Legacy School Benefit Booklet 2021-2022

BlueChoice HMO HSA/HRA Silver 3000 ON/OFF SHOP Summary of Benefits

Services In-Network You Pay 1
PRESCRIPTION DRUGS 9​
Formulary List​ Visit www.carefirst.com/acarx to locate Formulary List​
Annual Prescription Drug Deductible​ Subject to combined medical and prescription drug deductible​
Preventive Drugs​ No charge*​
Diabetic Supplies, Oral Chemo Drugs and​ No charge* after deductible​
Medication Assisted Treatment Drugs​
Generic Drugs​ 30-day supply Deductible, then $10;​
90-day supply Deductible, then $20 (maintenance drugs only)​
10
Preferred Brand Drugs (Preferred Insulin $0)​ 30-day supply Deductible, then $45;​
90-day supply Deductible, then $90 (maintenance drugs only)​
Non-preferred Brand Drugs 11​ 30-day supply Deductible, then $65;​
90-day supply Deductible, then $130 (maintenance drugs only)​
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)​ In-network-No charge*; Out-of-network-Total charge minus $40 reimbursement​
Frames and Contact Lenses—Pediatric​ In-network-No charge*; Out-of-network-Reimbursements apply​
Collection Only​
Spectacle Lenses​ In-network-No charge*; Out-of-network-Reimbursements apply​
PEDIATRIC DENTAL—(Through the end of the calendar year in which the dependent turns 19)​
Annual Dental Deductible​ In-network-$25; Out-of-network-$50​
Class I Preventative & Diagnostic Services—​ In-network-No charge*; Out-of-network-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​ In-network-Deductible, then 20% of Allowed Benefit; Out-of-network-Deductible, then​
composite), simple extractions, non-surgical​ 40% of Allowed Benefit​
periodontics​
Class III Major Services—Surgical periodontics,​ In-network-Deductible, then 20% of Allowed Benefit; Out-of-network-Deductible, then​
endodontics, oral surgery​ 40% of Allowed Benefit​
Class IV Major Services—Restorative Crowns,​ In-network-Deductible, then 50% of Allowed Benefit; Out-of-network-Deductible, then​
dentures, inlays and onlays​ 65% of Allowed Benefit​
Class V Medically Necessary Orthodontic​ In-network-50% of Allowed Benefit; Out-of-network-65% of Allowed Benefit​
Services​

SUM5150-1P (9/20) ■ MD ■ 2021 2-50 ACA Compliant (Can be sold as HDHP)​