Page 18 - Empowered Learning for Dyslexic Children Benefits Guide 2022-2023
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BlueChoice HMO HSA/HRA Bronze 6100 ON/OFF
SHOP Summary of Benefits
Non-Integrated Deductible
Services In-Network You Pay 1
Visit www.carefirst.com/doctor to locate providers and facilities
24-HOUR NURSE ADVICE LINE
Free advice from a registered nurse. When your doctor is not available, call 800-535-9700 to speak with a registered nurse
Visit www.carefirst.com/needcare to learn about your health questions and treatment options.
more about your options for care.
WELLNESS PROGRAM & BLUE REWARDS
Visit www.carefirst.com/sharecare for more You have access to a comprehensive wellness program as part of your medical plan.
information. You also have Blue Rewards, an incentive program where you can get rewarded for
completing certain activities.
ANNUAL MEDICAL DEDUCTIBLE (Benefit Period) 2
Individual/Family $6,100 Individual/$12,200 Family (separate)
ANNUAL OUT-OF-POCKET MAXIMUM (Benefit Period) 3,4
Individual/Family $6,900 Individual/$13,800 Family (separate)
PREVENTIVE SERVICES
Well-Child Care No charge*
(including exams & immunizations)
Adult Physical Examination (including routine No charge*
GYN visit)
Breast Cancer Screening No charge*
Pap Test No charge*
Prostate Cancer Screening No charge*
Colorectal Cancer Screening No charge*
PCP AND SPECIALIST SERVICES
5
FACILITY CHARGE —In addition to the physician Deductible, then $50 per visit
copays/coinsurances listed below, if a service
is rendered on a hospital campus, ADD facility
charge if applicable (also applies to Artificial
Insemination and In Vitro Fertilization on page
2)
Office Visits for Illness—PCP 5,6 Deductible, then $50 per visit
Office Visits for Illness—Specialist 5,6 Deductible, then $100 per visit
Allergy Testing 5 Deductible, then $100 per visit
Allergy Shots 5 Deductible, then $100 per visit
Physical, Speech, and Occupational Therapy 5 Deductible, then $100 per visit
(limited to 30 visits/illness or injury/benefit
period)
Chiropractic 5 Deductible, then $100 per visit
(limited to 20 visits/benefit period)
Acupuncture 5 Deductible, then $100 per visit
IMMEDIATE AND EMERGENCY SERVICES
Convenience Care (retail health clinics such as Deductible, then $50 per visit
CVS MinuteClinic or Walgreens Healthcare
Clinic)
Urgent Care Center Deductible, then $100 per visit
(such as Patient First or ExpressCare)
Hospital Emergency Room Services
■ Facility Deductible, then $250 per visit (waived if admitted)
■ Physician Deductible, then $100 per visit
Ambulance (if medically necessary) Deductible, then $100 per service
SUM5575-1P (9/21) ■ MD ■ 2022 2-50 ACA Compliant (Can be sold as HDHP)
