Page 13 - Empowered Learning for Dyslexic Children Benefits Guide 2022-2023
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BlueChoice Plus 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 accessing laboratory services inside the CareFirst Service area (Maryland, D.C., Northern Virginia) must use LabCorp as their Lab Test
facility and a non-hospital/freestanding facility for X-rays and specialty Imaging for In-Network benefits. Services performed by any other
provider, while inside the CareFirst Service area will be considered Out-of-Network. Members accessing laboratory, X-rays, and specialty Imaging
services outside of Maryland, D.C. or Northern Virginia, may use any participating BlueCard PPO facility and receive out-of-network benefits.
10 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.
11 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.
12 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.
13 If a Generic drug becomes available for a Preferred Brand drug, the Preferred Brand drug moves to the Non-preferred Brand drug tier.
14 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: In-network:MD/CFBC/GC (1/14); MD/CFBC/SG/2019 GC AMEND (1/19);
MD/CFBC/SG/HMO-POS/EOC (1/22); MD/CFBC/DOL APPEAL (R. 9/11); MD/CFBC/SG/PLUS IN/DOCS (1/17); MD/CFBC/SG/POS IN CDH/SIL 1500 (1/22);
MD/CFBC/SG/POS IN CDH/SIL 2500 (1/22); MD/CFBC/SG/POS IN/GOLD 500 (1/22); MD/CFBC/SG/POS PLUS IN/GOLD 1000 (1/22); MD/CFBC/SG/POS
PLUS IN CDH/BRZ 6100 (1/22); MD/CFBC/SG/POS PLUS IN CDH/SIL 3000 (1/22); MD/CFBC/BLCRD (5/12); MD/CFBC/MEM/BLCRD (1/12);
MD/CFBC/SG/ELIG AMEND (1/17); MD/CFBC/SG/2022 AMEND (1/22); MD/CFBC/SG/PLUS/HMO/AUTH AMEND (1/20); MD/CFBC/GRP/FAM PLAN
(1/20); CFBC – DISCLOSURE 10/15; MD/CFBC/SG/HMO-POS IN/INCENT (R. 1/22); MD/CFBC/SHOP/PARTNER (1/14); MD/PT PROTECT (9/10);
MD/CFBC/ELIG (1/14) and any amendments. Out-of-Network:MD/CF/GC (1/14); MD/CF/SG/2019 GC AMEND (1/19); MD/CF/SG/POS OON/EOC (R.
1/22); MD/GHMSI/DOL APPEAL (R. 9/11); MD/CF/SG/POS OON/DOCS (R. 1/17); MD/CF/SG/POS OON CDH/SIL 1500 (1/22); MD/CF/SG/POS OON
CDH/SIL 2500 (1/22); MD/CF/SG/POS OON/GOLD 500 (1/22); MD/CF/SG/POS PLUS OON CDH/BRZ 6100 (1/22); MD/CF/SG/POS PLUS OON CDH/SIL
3000 (1/22); MD/CF/SG/POS PLUS OON/GOLD 1000 (1/22); MD/CF/BLUECARD (5/12); MD/CF/ANCILLARY AMEND (10/12); MD/CF/SG/2022 AMEND
(1/22); MD/CF/SG/OON/AUTH AMEND (1/20); MD/CF/GRP/FAM PLAN (1/20); GHMSI – DISCLOSURE 10/15; MD NCA-HEALTH GUARANTY 10/12;
MD/CF/SHOP/PARTNER (1/14); MD/PT PROTECT (9/10); MD/CF/ELIG (1/14) and any amendments. Out-of-Network:CFMI/GC (1/14); CFMI/SG/2019
GC AMEND (1/19); CFMI/SG/POS OON/EOC (R. 1/22); CFMI/DOL APPEAL (R. 9/11); CFMI/SG/POS OON/DOCS (R. 1/17); CFMI/SG/POS OON CDH/SIL
1500 (1/22); CFMI/SG/POS OON CDH/SIL 2500 (1/22); CFMI/SG/POS OON/GOLD 500 (1/22); CFMI/SG/POS PLUS OON CDH/BRZ 6100 (1/22);
CFMI/SG/POS PLUS OON CDH/SIL 3000 (1/22); CFMI/SG/POS PLUS OON/GOLD 1000 (1/22); CFMI/BLUECARD (5/12); CFMI/BLUECARD-MEMBER
(1/12); MD/CFMI/ANCILLARY AMEND (10/12); CFMI/SG/2022 AMEND (1/22); CFMI/SG/OON/AUTH AMEND (1/20); CFMI/GRP/FAM PLAN (1/20);
CFMI-DISCLOSURE 10/15; CF-HEALTH GUARANTY 10/12; 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. CareFirst MedPlus is the business
name of First Care, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the business name of CareFirst Advantage, Inc. CareFirst of Maryland, Inc., Group Hospitalization and
Medical Services, Inc., The Dental Network, Inc., First Care, Inc., CareFirst BlueChoice, Inc., and CareFirst Advantage, Inc. 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.
SUM5584-1P (9/21) ■ MD ■ 2022 2-50 ACA Compliant (Can be sold as HRA)
