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BlueChoice HMO HSA/HRA Silver 1500 ON/OFF SHOP 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 Aggregate - For family coverage only: The family deductible must be met before any member starts receiving benefits. The deductible may be
met by one member or any combination of members.
3 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.
4 All drug costs are subject to the in-network out-of-pocket maximum.
5 If a service is rendered on a hospital campus you could receive two bills, one from the physician and one from the facility.
6 “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.
7 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.
8 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.
9 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.
10 If a Generic drug becomes available for a Preferred Brand drug, the Preferred Brand drug moves to the Non-preferred Brand drug tier.
11 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.
Reminder: To enroll in HMO, HMO Referral and Plus plans, members must live or work within the CareFirst service area of Maryland,
Washington, D.C. or Northern Virginia.
Note: Upon enrollment in CareFirst BlueChoice, you will need to select a Primary Care Provider (PCP). To select a PCP, go to
www.carefirst.com/findadoc for the most current listing of PCPs from our online provider directory. You may also call the Member
Services number on the back of your CareFirst ID card for assistance in selecting a PCP or obtaining a printed copy of the CareFirst
BlueChoice provider directory.
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/CFBC/SHOP/GC (1/14); MD/CFBC/SHOP/2019 GC AMEND (1/19);
MD/CFBC/SHOP/HMO/EOC (R. 1/22); MD/CFBC/DOL APPEAL (R. 9/11); MD/CFBC/SHOP/HMO DOCS (R. 1/17); MD/CFBC/SHOP/HMO OA CDH/BRZ
6100 (1/22); MD/CFBC/SHOP/HMO OA CDH/SIL 1500 (1/22); MD/CFBC/SHOP/HMO OA CDH/SIL 2400 (1/22); MD/CFBC/SHOP/HMO OA CDH/SIL
3000 (1/22); MD/CFBC/SHOP/HMO OA/GOLD 1000 (1/22); MD/CFBC/SHOP/HMO OA/GOLD 1500 (1/22); MD/CFBC/SHOP/HMO OA/SIL 5000 (1/22);
MD/CFBC/SHOP/HMO VALUE/BRONZE 6000 (1/22); MD/CFBC/BLCRD (5/12); MD/CFBC/MEM/BLCRD (1/12); MD/CFBC/SHOP/2022 AMEND
(1/22);MD/CFBC/SHOP/ELIG AMEND (R. 1/19); MD/CFBC/SG/PLUS/HMO/AUTH AMEND (1/20); MD/CFBC/GRP/FAM PLAN (1/20); CFBC – DISCLOSURE
12/13; MD/CFBC/SG/HMO-POS IN/INCENT (R. 1/22); MD/CFBC/SHOP/PARTNER (1/14); MD/PT PROTECT (9/10); MD/CFBC/SHOP/ELIG (1/14) and any
amendments. 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/SHOP/HMO OA CDH/BRZ 6100 (1/22); MD/CFBC/SHOP/HMO OA CDH/SIL 1500 (1/22); MD/CFBC/SHOP/HMO OA CDH/SIL 2400 (1/22);
MD/CFBC/SHOP/HMO OA CDH/SIL 3000 (1/22); MD/CFBC/SHOP/HMO OA/GOLD 1000 (1/22); MD/CFBC/SHOP/HMO OA/GOLD 1500 (1/22);
MD/CFBC/SHOP/HMO OA/SIL 5000 (1/22); MD/CFBC/SHOP/HMO VALUE/BRONZE 6000 (1/22); MD/CFBC/SG/HMO OA CDH/BRZ 6500 90 (1/22);
MD/CFBC/SG/HMO OA CDH/GOLD 1500 (1/22); MD/CFBC/SG/HMO OA CDH/GOLD 1500 90 (1/22); MD/CFBC/SG/HMO OA CDH/SIL 2000 (1/22);
MD/CFBC/SG/HMO OA CDH/SIL 2100 70 (1/22); MD/CFBC/SG/HMO OA CDH/SIL 3000 70 (1/22); MD/CFBC/SG/HMO OA/GOLD 500 (1/22);
MD/CFBC/SG/HMO OA/GOLD 3000 (1/22); MD/CFBC/SG/HMO OA/PLAT 0 (1/22); MD/CFBC/SG/HMO OA/SIL 1500 (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 12/13; 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.
CareFirst BlueChoice, Inc. is an independent licensee 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.
SUM5569-1P (9/21) ■ MD ■ 2022 2-50 ACA Compliant (Can be sold as HDHP)
