Professional services of physicians

• In physician's office
• Inpatient/Skilled nursing Professional (Non- Surgical)
• Outpatient Professional (Non-Surgical)
• Office medical consultations
• Second surgical opinion

Office/Outpatient Hospital

In-network:

• No copay
• Specialist - $40 copay

Out-of-network:

• $80 copay

Note: Office visits rendered in a hospital, hospital clinic or health care provider’s office visit on a hospital campus are not subject to the facility copay.

Inpatient Hospital/Skilled Nursing

In-network:

• 20% of plan allowance 

Out-of-network:

• 30% of plan allowance 

Office/Outpatient Hospital

In-network:

• PCP - $15 copay
• Specialist - $50 copay

Note: Office visits rendered in a hospital, hospital clinic or health care provider’s office visit on a hospital campus are not subject to the facility copay.

Inpatient Hospital/Skilled Nursing

In-network:

• 25% of plan allowance 

Convenience Care (Retail Health Clinic)

While primary care providers should be the first line of defense for members, there are tiered care alternatives members can access when their PCP is not available such as CVS MinuteClinic, Walgreens TakeCare and Target Clinic who can serve as the immediate backup to PCPs. (after hours)

In-network:

• $0 copay

Out-of-network:

• $80 copay per visit

In-network:

• $15 copay

Telemedicine Services/CareFirst Video Visits:

• Benefits are available to the same extent as benefits provided for other services.
• Example:
  • If services are rendered by a PCP, the member would be responsible for the PCP cost-share.
  • If services are rendered by a Specialist, the member would be responsible for the Specialist cost-share. 

Note: Members have a 24/7 access to on-demand video consultations with board certified physicians with CareFirst Video Visit. 

Please visit: www.Carefirstvideovisit.com 

Benefits are available to the same extent as benefits provided for other services

Benefits are available to the same extent as benefits provided for other services

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology
• X-rays
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG

Office/Freestanding Setting:
In-Network

• Labs - No copay
• X-rays - $40 copay
• Other Diagnostic Services - $40 copay

Out-of-Network

• Labs - No copay
• X-rays - $40 copay
• Other Diagnostic Services - $40 copay

Office/Freestanding Setting:
In-Network

• Labs - $30 copay
• X-rays - $50 copay
• Other Diagnostic Services - $50 copay

Specialty Imaging:

• MRA/MRS
• MRI
• PET
• CT/CAT scans

In-Network:

$75 copay

Out-of-Network:

$75 copay

In-Network:

$100 copay

Routine physical every year which includes screenings. The following preventive services are covered at the time interval recommended at each of the links below:

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV).  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
• Individual counseling on prevention and reducing health risks
• Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Note: Genetic Testing: Prior Authorization is required for genetic testing. Ordering providers must obtain authorization for all genetic tests either by accessing the CareFirst provider portal under Pre-Auth/Notifications or calling AIM directly at (844) 377-1277. HLA Typing/Preimplantation (related to in vitro fertilization) may require authorization through the health plan and can be managed in CareFirst’s provider portal under Medical Prior Authorization and no authorization is required for Cologuard®.

In-network:

• No copay

Out-of-network: 

• No office copay

In-network:

• No copay

Routine Prostate Specific Antigen (PSA) test - one (1) annually for men age 40 and older in accordance with the most current American Cancer Society guidelines.

In-network:

• No copay

Out-of-network: 

• No copay

In-network:

• No copay

Routine mammogram - covered for women

In-network:

• No copay

Out-of-network:

• No copay

In-network:

• No copay

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

In-network:

• No copay

Out-of-network:

• No copay

In-network:

• No copay

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

• Well-child visits, examinations, and immunizations other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org

• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of  immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html

• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

Note: Any procedure, injection, diagnostic service, laboratory, or x-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

In-network:

• No copay

Out-of-network:  

• No copay

In-network:

• No copay

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes for pregnant women
• Delivery
• Postnatal care

NOTE: Members are responsible for both physician and facility fees. Please refer to section 5C for outpatient or inpatient facility fees.

1. Preventive Services:
a) Preventive outpatient obstetrical care of an uncomplicated pregnancy, including prenatal evaluation and management office visits and one postpartum office visit;

b) Prenatal laboratory tests and diagnostic services related to the outpatient care of an uncomplicated pregnancy, including those identified in the current recommendations of the United States Preventive Services Task Force that have in effect a rating of "A" or "B" or provided in the comprehensive guidelines for women's preventive health supported by the Health Resources and Services Administration;

c) Preventive laboratory tests and services rendered to a newborn during a covered hospitalization for delivery, identified in the current recommendations of the United States Preventive Services Task Force that have in effect a rating of "A" or "B," the Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care, and the Uniform Panel of the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children, including the collection of adequate samples for hereditary and metabolic newborn screening and newborn hearing screening; and

2. Non-Preventive Services:
a) Outpatient obstetrical care and professional services for all prenatal and post-partum complications, including prenatal and post-partum office visits and ancillary services provided during those visits.

b) Birthing classes, one course per pregnancy, at a CareFirst BlueChoice approved facility;

3. Professional Services at Delivery - Professional services are covered under Section 5(a). 

In-network:

• Preventive- No charge
• Non-Preventive- No charge
• Professional Services at Delivery - 20% of plan allowance

Out-of-network:

• Preventive- No charge
• Non-Preventive- No charge
• Professional Services at Delivery - 30% of plan allowance

Note: For non-routine maternity admissions, the member is responsible for obtaining authorization for services rendered outside of the service area and services rendered by out-of-network non-participating providers.

In-network:

• Preventive- No charge
• Non-Preventive- $50
• Professional Services at Delivery - 25% of plan allowance

Breastfeeding support, supplies and counseling for each birth.

Note: Benefit coverage for breastfeeding support, supplies and counseling for each birth begin immediately after delivery.

Note: Breastfeeding support benefits include but are not limited to the following: comprehensive lactation support, lactation counseling, and rental or purchase of a breast pump and related supplies in conjunction with each birth. These benefits begin immediately following delivery.

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see page (Applies to printed brochure only) for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

In-network:

• No copay

Out-of-network:

• No copay

In-network:

• No copay

A range of voluntary family planning services, limited to:

• Voluntary sterilization for a woman
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo-Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Contraceptive counseling on an annual basis at no cost sharing.

Note: We cover oral contraceptives under the prescription drug benefit.

In-network:

• No copay

Out-of-network:

• No copay

In-network:

• No copay

Contraceptive procedures for men

Hospital services are covered under Sect. 5(c)

Surgical benefits are covered under Sect. 5(b)

In-network:

• No copay for PCP
• Specialist - $40 copay

Out-of-network:

• $80 copay

In-network:

• PCP - $15 copay
• Specialist - $50 copay

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic counseling
• Fertility drugs for procedures excluded under this contract.
• Elective Abortion

Diagnosis and treatment of infertility such as:

• Artificial insemination:
  • Intravaginal Insemination (IVI)
  • Intracervical Insemination (ICI)
  • Intrauterine Insemination (IUI)

Note:

• We cover drugs for the treatment of infertility, unless they are prescribed for procedures not covered under this plan. When covered, injectable drugs are medical benefits, and oral drugs are benefits under prescription drug coverage. See Section 5(g).
• Prior authorization for the treatment must be obtained from CareFirst BlueChoice.
• Benefits are limited to six (6) attempts per live birth.
• Any charges associated with the collection of the sperm will not be covered unless the partner is also a member.
• The member is responsible for the copayment or coinsurance for artificial insemination stated in the Schedule of Benefits.
• Coverage is subject to the exclusions listed in the Exclusions and Limitations Section at the end of this Description of Covered Services.
• Procedure is covered regardless of whether the couple has a relationship under which the FEHB Program recognizes each partner as a spouse of the other.
• Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

In-network:

• 50% coinsurance

Out-of-network:

• 50% coinsurance

Diagnosis of infertility only covered

In-network:

• PCP - $15 copay
• Specialist - $50 copay

Note: Artificial insemination is not covered

Iatrogenic infertility

Standard Fertility Preservation for members who have been diagnosed with Iatrogenic Infertility:

• the collection of sperm
• cryopreservation of sperm
• collection of embryo
• cryopreservation of embryo
• collection of oocyte
• cryopreservation of oocyte
• benefits limited to up to 12 months of storage of sperm, oocytes and embryo

Prior authorization for the treatment must be obtained from CareFirst BlueChoice.

Benefits are limited to six (6) attempts per live birth.

In-network:

• 50% coinsurance

Out-of-network:

• 50% coinsurance

Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

Not Covered 

Not covered:

• In vitro fertilization (IVF)
• Embryo transfer and gamete intra-fallopian transfer (GIFT),
• Zygote intra-fallopian transfer (ZIFT)
• Intrauterine and Assisted reproductive technology (ART) procedures, such as:
  • Services and supplies related to ART procedures
  • Cost of donor sperm
  • Cost of donor egg
  • Drugs for non-covered procedure

• Testing and treatment
• Allergy injections

In-network:

• No copay for PCP
• Specialist - $40 copay

Out-of-network:

• $80 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

In-network:

• PCP - $15 copay
• Specialist - $50 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

In-network:

• No copay for PCP
• Specialist - $40 copay

Out-of-network:s

• $80 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

In-network:

• PCP - $15 copay
• Specialist - $50 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

Not covered: Provocative food testing and Sublingual allergy desensitization

• Radiation therapy
• Respiratory and inhalation therapy
• Dialysis - hemodialysis and peritoneal dialysis
• Growth hormone therapy (GHT)

Members are responsible for both physician and facility fees. Please refer to section 5C for outpatient or inpatient facility fees.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary.

For services rendered by Home Health provider see Home Health benefits on page(Applies to printed brochure only).

In-network:

• No copay for PCP
• Specialist - $40 copay

Out-of-network:

• $80 copay

In-network:

• PCP - $15 copay
• Specialist - $50 copay

Up to 60 visits (combined physical, occupational and/or speech therapy) per condition per benefit period for the services of the following qualified providers:

• Physical therapists
• Occupational therapists
• Speech therapists

Note: Coverage shall include Physical Therapy, Occupational Therapy and Speech Therapy for the treatment of individuals who have sustained an illness or injury that CareFirst BlueChoice determines to be subject to improvement

Note: We only cover therapy when a physician:

- orders the care

- identifies the specific professional skills the patient requires and the medical necessity for skilled services; and

- indicates the length of time the services are needed. 

Note: Occupational Therapy is limited to the use of purposeful activity or interventions designed to achieve functional outcomes that promote health, prevent injury or disability, and that develop, improve, sustain or restore the highest possible level of independence of an individual.

Brochure language also states under member liability:

• Other than any applicable inpatient or outpatient facility copay, member has no copay or coinsurance during an approved inpatient stay.

See Section 5 (c) for information on outpatient facility services.

In-network:

• Specialist - $40 copay

Out-of-network:

• $80 copay

In-network:

• Specialist - $50 copay

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• Maintenance therapy

• Habilitative Services are services, including Occupational Therapy, Physical Therapy, and Speech Therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child's ability to function.
• Benefits are subject to the applicable Occupational Therapy, Physical Therapy, and Speech Therapy copay but are not counted toward any visit maximum for therapy services.
• Habilitative Therapy ABA coverage for Applied Behavioral Analysis include Verbal Behavior therapy, Occupation Therapy, Physical Therapy and Speech Therapy from 18 months to 21 years of age. There will be no visit maximums and preauthorization will be required.
• Note: Members are responsible for both physician and facility fees. Please refer to section 5(c) for outpatient facility fees.

In-network:

• Specialist - $40 copay

Out-of-network:

• $80 copay

• Note: Member is responsible for obtaining authorization for services rendered outside of the service area and services by out-of-network non-participating providers.

In-network:

• Specialist - $50 copay

Not Covered: Benefits for Habilitative Services delivered through early intervention or school services.

All charges

Up to 90 visits per condition per benefit period

Note: Cardiac Rehabilitation benefits are provided to Members who:

• have been diagnosed with significant cardiac disease
• suffered a myocardial infarction
• undergone invasive cardiac treatment immediately preceding referral

Note: Members are responsible for both physician and facility fees. Please refer to section 5(c) for outpatient or inpatient facility fees.

In-network:

• Specialist - $40 copay

Out-of-network:

• $80 copay

In-network:

• Specialist - $50 copay

Note: Benefits are not provided for maintenance cardiac rehabilitation

Pulmonary Rehabilitation

• For those who have significant pulmonary disease or who have undergone certain surgical procedures of the lung.
• Limited to one (1) pulmonary rehabilitation program per lifetime.
• Benefits are not provided for maintenance programs

Note: Members are responsible for both physician and facility fees. Please refer to section 5(c) for outpatient or inpatient facility fees.

In-network:

• Specialist - $40 copay

Out-of-network:

• $80 copay

In-network:

• Specialist - $50 copay

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O. or audiologist

Note: For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care.

In-network:

• Specialist - $40 copay

Out-of-network:

• $80 copay

In-network:

• Specialist - $50 copay

Hearing Aids

• One (1) medically necessary hearing aid per ear is covered up to our plan allowance each 36 months.

Note: Medical devices, such as bone anchored hearing aids (BAHA) and cochlear implants, (that or which) are surgically implanted see Orthopedic and Prosthetic Supplies. For additional details, see page (Applies to printed brochure only) under the Orthopedic and prosthetic supplies.

In-network:

• 15% of Plan Allowance                          

Note: Limited to $1,500 payment per ear per 36 months

Out-of-network:

• 15% of Plan Allowance                                                                               

Note: Limited to $1,500 payment per ear per 36 months

Provider may bill any amount in excess of our allowance (out-of-network). Participating providers will advise you in writing in advance if you will have a balance.

In-network:

• 50% of the plan allowance

Note: Limited to $1,000 payment per ear per 36 months

Not covered:

• Hearing services that are not shown as covered.

Medical Vision Services

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)
• Annual eye refractions
• Medical eye exams

Note: This is a medical benefit not a vision benefit

In-network:

• Specialist - $40 copay 

Out-of-network:

• $80 copay

In-network:

• Specialist - $50 copay

Routine eye exams

Note: See Preventive care, children for eye exams for children

Note: Eye care and exams related to medical conditions are subject to the specialist copay

In-network:

• $10 per visit at Davis Vision Providers

Out-of-network:

• All charges above $33

In-network:

• $10 per visit at Davis Vision Providers

Not covered:

• Eyeglasses  or contact lenses (except as listed above)
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Eyeglasses, contact lenses, routine eye examinations, or vision testing for the prescribing or fitting of eyeglasses or contact lenses except as provided by Davis Vision.
• Deluxe eyeglass frames or lens features for eyeglasses or contact lenses such as special coating, polarization, UV treatment, etc.
• Multifocal, accommodating, toric, or other premium intraocular lenses (IOLs) including Crystalens, ReStor, and ReZoom
• Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia and strabismus as described above
• LASIK, INTACS, radial keratotomy, and other refractive surgical services
• Refractions, including those performed during an eye examination related to a specific medical condition.

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

In-network:

• No copay for PCP
• Specialist - $40 copay 

Out-of-network:

• $80 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

In-network:

• PCP - $15 copay
• Specialist - $50 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

Not covered:

• Other routine palliative or cosmetic care of the feet including flat foot conditions, supportive devices for the foot, treatment of sublaxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toe nails, fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet.

• Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Hair Prosthesis (wig) is covered when prescribed by a treating oncologist and the hair loss is the result of chemotherapy. The Plan will cover up to $350 for one (1) hair prosthesis per benefit period.
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants.
• Internal prosthetic devices such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.
• Medically Necessary molded foot orthotics

Notes: For information on the professional charges for the surgery to insert an implant. See Section 5(b) Surgical procedures. For information on the hospital and or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance service.

In-Network:

• 25% of plan allowance per device

Out-of-network:

• 50% of plan allowance per device

In-Network:

• 25% of plan allowance per device

Not covered:

• Orthopedic and corrective shoes
• Arch supports, heel pads, and heel cups  (except as listed under Orthopedic and prosthetic devices)
• Over the counter orthotics
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Wigs, including cranial prostheses, unless otherwise specified
• Prosthetic replacements provided less than three (3) years after the last one we covered
• Prosthetic devices such as artificial limbs and lenses following cataract removal unless covered under the DME benefit (see Durable Medical Equipment below)

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Audible prescription reading devices
• Speech generating devices
• Canes
• Diabetic shoes
• Commodes
• Glucometers
• Suction machines
• Medical supplies (i.e. ostomy and catheter supplies, dialysis supplies, medical foods for inherited metabolic diseases and Inborn Errors of Metabolism (IEM)
• Externally worn non-surgical durable devices which replace a body part or assist a patient in performing a bodily function (unless otherwise described in the "orthopedic and prosthetic devices" section above)
• Externally worn braces which improve the function of a limb
• Medically Necessary fitted compression stockings

Note: Prior authorization is required for certain in-network DME covered services. In-network providers will obtain prior authorization on behalf of the member. See https://provider.carefirst.com/providers/medical/in-network-precertification-preauthorization.page for a list of specific Covered Services which require prior authorization.

In-Network:

• 25% of plan allowance up to allowed benefit

Diabetic Supplies- 25% of plan allowance up to $100 for a 30-day supply

Out-of-network:

• 50% of plan allowance up to allowed benefit.

Diabetic Supplies- 50% of plan allowance up to $100 for a 30-day supply

In-Network:

• 25% of plan allowance up to allowed benefit

Diabetic Supplies- 25% of plan allowance up to $100 for a 30-day supply

Not covered:

• Eye glasses and contact lenses (except as listed under Vision Services)
• Dental prosthetics (except as listed under Orthopedic and Prosthetics above)
• Foot orthotics (except as listed under Orthopedic and Prosthetics above)
• Environment control products
• Over the counter compression stockings
• Medical equipment of an expendable nature (i.e. ace bandages, incontinent pads)
• Replacement of DME equipment not due to normal wear and tear
• Comfort and convenience items
• Over the counter items, except as listed above
• Exercise equipment
• Equipment that can be used for non-medical purposes

All charges

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Services include oxygen therapy.
• Home health care-Postpartum visits limited to two (2) per plan year.
• Home health care-Post Mastectomy/Testicle Removal visits limited to four (4) per plan year.

In-network:

• $40 per visit copay

Out-of-network:

• $80 per visit copay

In-Network:

• No Charge

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient's family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Private duty nursing

Chiropractic services, limited to spinal manipulation, evaluation, and treatment up to a maximum of 20 visits per benefit period when provided by a Plan chiropractor.

In-network:

• Specialist - $40 copay

Out-of-network:

• $80 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

In-Network:

• Specialist - $50 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

Not covered:

Services other than for musculoskeletal conditions of the spine.

Acupuncture, Limited to 20 visits per Benefit Period.

In-network:

• Specialist - $40 copay

Out-of-network:

• $80 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

In-Network:

• Specialist - $50 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback

Coverage is provided for:

• Diabetes self-management (sponsored by the Plan's Health Education Department)
• Tobacco and nicotine cessation programs, including individual, group, phone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to quit nicotine dependence. Coverage for counseling for up to two quit attempts per year. (All medications will require a prescription to be covered, to include those that are available over the counter)
• Prescribed medications approved by the FDA to treat tobacco dependence will be covered in full under the pharmacy benefit. See page 76.
• Childhood obesity as part of routine child care visit
• Medically necessary nutrition therapy
• Medically necessary professional nutritional counseling

In-network:

• No copay

Out-of-network:

• No copay

In-network:

• No copay

Note:

Benefits for all other types of health education classes and self-help programs that are not offered through the Plan's Health Education program are not covered.

CareFirst BlueChoice has created a network of providers that have agreed to oversee this program. The main objective of this approach is diligent monitoring of sleep apnea patients to ensure compliance with their treatment and reducing any further medical complications arising from sleep disorders. CareFirst BlueChoice has also removed barriers, such as prior authorizations, to acquiring sleep apnea equipment such as CPAP machines.

In-network:

• Home - No copay
• Office - $40 copay
• Freestanding - $40 copay
• Outpatient Hospital - $150 copay

Out-of-network:

• Home - $50 copay
• Office - $80 copay
• Freestanding - $80 copay
• Outpatient Hospital - $200 copay

In-network:

• Home - No copay
• Office - $50 copay
• Freestanding - $50 copay
• Outpatient Hospital - $200 copay

Infusion Services means treatment provided by placing therapeutic agents into the vein, and parenteral administration of medication and nutrients. Infusion Services also includes enteral nutrition, which is the delivery of nutrients by tube into the gastrointestinal tract. Infusion Services includes all medications administered intravenously and/or parenterally.

Infusion Services: Prior Authorization required for Specialty Drugs

• Transfusion services and Infusion Services, including
• home infusions,
• infusion of therapeutic agents,
• medication and nutrients,
• enteral nutrition into the gastrointestinal tract,
• chemotherapy, and
• prescription medications.
• Blood and Blood Products (including derivatives and components) that are not replaced by or on behalf of the member

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants.

In network:

• Home/Office/Freestanding - $40 copay
• Outpatient Hospital - $200 copay

Out-of-network:

• Home/Office/Freestanding - $80 copay
• Outpatient Hospital- $200 copay

In network:

• Home/Office/Freestanding - $20 copay
• Outpatient Hospital - $200 copay

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery)

Note: You must meet certain criteria to be eligible for bariatric surgery. They include:

• A body mass index that is greater than 40 kilograms per meter squared; or
• Equal to or greater than 35 kilograms per meter squared with a co-morbid medical condition, including hypertension, a cardiopulmonary condition, sleep apnea or diabetes.

Please contact Member Services at (888)-789-9065 for more details on bariatric surgery.

• Insertion of internal prosthetic devices.      See 5(a) – Orthopedic and prosthetic devices for device coverage information
• Voluntary sterilization (e.g., vasectomy)
• Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.  No additional copay  is required for internal prostheses (devices).

Note: See Section 5(c) about possible outpatient facility or inpatient hospital admission copayment

In-network

Office:

• PCP – No copay
• Specialist – $40 copay 

Ambulatory Surgical Center (ASC):

• PCP – No copay
• Specialist – $40 copay

Outpatient Hospital:

• PCP – No copay
• Specialist – $40 copay

Inpatient Hospital:

• 20% of plan allowance

Out-of-Network

Office:

•  $80 copay

Ambulatory Surgical Center (ASC):

• $80 copay

Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• 30% of plan allowance

In-network

Office:

• PCP – $15 copay
• Specialist – $50 copay 

Ambulatory Surgical Center (ASC):

• PCP – $15 copay
• Specialist – $50 copay

Outpatient Hospital:

• PCP – $15 copay
• Specialist – $50 copay

Inpatient Hospital:

• 25% of plan allowance

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)

Gender Affirming Services

We cover medically necessary care including where appropriate gender reassignment surgery, hormone therapy, and psychotherapy. Transgender services include, but are not limited to, medical counseling, behavioral health services, hormonal therapy, reconstructive surgery and cosmetic surgery. Please note some cosmetic surgery may be specifically excluded. Prior authorization for transgender services is required. The provider must submit a request for services and clinical information prior to the anticipated date of service through the CareFirst BlueChoice authorization portal or by fax. The clinical information is reviewed for persistent, well-documented gender dysphoria, the capacity to make a fully informed decision and to consent for treatment, age of majority in a given state, documentation to support any significant medical or mental health concerns are reasonably well controlled, and a history of hormone therapy for certain procedures. The request is reviewed according to the member’s contract, CareFirst BlueChoice’s Operating Procedure for Transgender Services, and CareFirst BlueChoice’s Medical Policy for Cosmetic and Reconstructive Surgery. The request is then reviewed by a Medical Director for final determination.

The gender reassignment surgeries that may be performed for transwomen (male to female) include but are not limited to:

• Orchiectomy:  removal of testicles
• Penectomy:  removal of penis
• Vaginoplasty:  creation of vagina
• Clitoroplasty:  creation of clitoris
• Labiaplasty:  creation of labia
• Prostatectomy:  removal of prostate
• Urethroplasty:  creation of urethra
• Mammoplasty:  breast augmentation

 The gender reassignment surgeries that may be performed for transmen (female to male) include but are not limited to:

• Salpingo-oophorectomy:  removal of fallopian tubes and ovaries
• Vaginectomy:  removal of vagina
• Vulvectomy:  removal of vulva
• Metoidioplasty:  creation of micro-penis using the clitoris
• Phalloplasty:  creation of penis, with or without urethra
• Hysterectomy:  removal of uterus
• Urethroplasty:  creation of urethra within penis
• Scrotoplasty:  creation of scrotum
• Testicular prosthesis:  implantation of artificial testes
• Mastectomy:  removal of the breast

In-network

Office:

• PCP – No copay
• Specialist – $40 copay

Ambulatory Surgical Center (ASC):

• PCP – No copay
• Specialist – $40 copay

Outpatient Hospital:

• PCP – No copay
• Specialist – $40 copay

Inpatient Hospital:

• 20% of plan allowance

Out-of-Network

Office:

•  $80 copay

Ambulatory Surgical Center (ASC):

• $80 copay

Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• 30% of plan allowance

In-network

Office:

• PCP – $15 copay
• Specialist – $50 copay 

Ambulatory Surgical Center (ASC):

• PCP – $15 copay
• Specialist – $50 copay

Outpatient Hospital:

• PCP – $15 copay
• Specialist – $50 copay

Inpatient Hospital:

• 25% of plan allowance

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Note: See Section 5(c) about possible outpatient facility or inpatient hospital admission copayment

In-network

Office:

• PCP – No copay
• Specialist – $40 copay

Ambulatory Surgical Center (ASC):

• PCP – No copay
• Specialist – $40 copay

Outpatient Hospital:

• PCP – No copay
• Specialist – $40 copay

Inpatient Hospital:

• 20% of plan allowance

Out-of-Network

Office:

•  $80 copay

Ambulatory Surgical Center (ASC):

• $80 copay

Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• 30% of plan allowance

In-network

Office:

• PCP – $15 copay
• Specialist – $50 copay 

Ambulatory Surgical Center (ASC):

• PCP – $15 copay
• Specialist – $50 copay

Outpatient Hospital:

• PCP – $15 copay
• Specialist – $50 copay

Inpatient Hospital:

• 25% of plan allowance

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures.

Note: See Section 5(c) for outpatient facility or inpatient hospital admission copays

In-network

Office:

• PCP – No copay
• Specialist – $40 copay

Ambulatory Surgical Center (ASC):

• PCP – No copay
• Specialist – $40 copay

Outpatient Hospital:

• PCP – No copay
• Specialist – $40 copay

Inpatient Hospital:

• 20% of plan allowance

Out-of-Network

Office:

•  $80 copay

Ambulatory Surgical Center (ASC):

• $80 copay

Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• 30% of plan allowance

In-network

Office:

• PCP – $15 copay
• Specialist – $50 copay 

Ambulatory Surgical Center (ASC):

• PCP – $15 copay
• Specialist – $50 copay

Outpatient Hospital:

• PCP – $15 copay
• Specialist – $50 copay

Inpatient Hospital:

• 25% of plan allowance

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Removal of impacted teeth
• Any other dental surgery not listed or the result of traumatic injury or treatment of cleft pallet

These solid organ transplants are subject to medical necessity and experimental/investigational review by the plan.  Refer to Other services in Section 3 for prior authorization procedures. 

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy ) only for patients with chronic pancreatitis.
• Cornea
• Heart
• Heart/lung
• Intestinal transplant
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-pancreas 
• Liver
• Lung single/bilateral/lobar
• Pancreas

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan.  Refer to other services in Section 3 for prior authorization procedure.

• Autologous tandem transplant for:
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

Note: See Section 5(c) about possible outpatient facility or inpatient hospital admission copayment.

In-network

Office:

• PCP – No copay
• Specialist – $40 copay

Ambulatory Surgical Center (ASC):

• PCP – No copay
• Specialist – $40 copay

Outpatient Hospital:

• PCP – No copay
• Specialist – $40 copay

Inpatient Hospital:

• 20% of plan allowance

Out-of-Network

Office:

•  $80 copay

Ambulatory Surgical Center (ASC):

• $80 copay

Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• 30% of plan allowance

In-network

Office:

• PCP – $15 copay
• Specialist – $50 copay 

Ambulatory Surgical Center (ASC):

• PCP – $15 copay
• Specialist – $50 copay

Outpatient Hospital:

• PCP – $15 copay
• Specialist – $50 copay

Inpatient Hospital:

• 25% of plan allowance

Blood or marrow stem cell transplants

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia  
  • Advanced Hodgkin’s lymphoma  with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL SLL)
  • Hemoglobinopathy
  • Infantile malignant osteoporosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and Related Disorders (i.e. Fanconi's PNH, pure red cell aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfilippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle Cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Advanced Childhood kidney cancers
  • Advanced Ewing sarcoma
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia  
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing's sarcoma
  • Mantle Cell (Non-Hodgkin Lymphoma)
  • Multiple myeloma
  • Medulloblastoma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular Mediastinal, Retroperitoneal, and ovarian germ cell tumors

Mini-transplants performed in a clinical trial setting (non-myeloblative reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other Services in Section 3 for prior authorization procedures:

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e.,myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPD's)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e. Fanconi's PNH. Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for:
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

Note: See Section 5c about possible outpatient facility or inpatient hospital admission copayment.

In-network

Office:

• PCP – No copay
• Specialist – $40 copay

Ambulatory Surgical Center (ASC):

• PCP – No copay
• Specialist – $40 copay

Outpatient Hospital:

• PCP – No copay
• Specialist – $40 copay

Inpatient Hospital:

• 20% of plan allowance 

Out-of-Network

Office:

•  $80 copay

Ambulatory Surgical Center (ASC):

• $80 copay

Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• 30% of plan allowance

In-network

Office:

• PCP – $15 copay
• Specialist – $50 copay 

Ambulatory Surgical Center (ASC):

• PCP – $15 copay
• Specialist – $50 copay

Outpatient Hospital:

• PCP – $15 copay
• Specialist – $50 copay

Inpatient Hospital:

• 25% of plan allowance

These blood or marrow stem cell transplants covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for:
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelinating polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple scleraes or sclerosis
  • Sickle cell anemia
• Mini-transplants (non-myeloablative allogeneic transplants, reduced intensity conditioning or RIC) for:
  • Acute lymphocytic or non-lymphocytic (i.e.,myelogenous) leukemia
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic myelogenous leukemia
  • Colon cancer
  • Chronic lymphocytic lymphoma/small cell lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myeloproliferative disorders (MPDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Aggressive non-Hodgkin lymphomas
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Chronic myelogenous leukemia
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis
• National Transplant Program (NTP)

Note: We cover related medical and hospital expenses of the donor when we cover the recipient who is not covered by other insurance. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

Note: See Section 5c about possible outpatient facility or inpatient hospital admission copayment.

In-network

Office:

• PCP – No copay
• Specialist – $40 copay

Ambulatory Surgical Center (ASC):

• PCP – No copay
• Specialist – $40 copay

Outpatient Hospital:

• PCP – No copay
• Specialist – $40 copay

Inpatient Hospital:

• 20% of plan allowance

Out-of-Network

Office:

•  $80 copay

Ambulatory Surgical Center (ASC):

• $80 copay

Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• 30% of plan allowance

In-network

Office:

• PCP – $15 copay
• Specialist – $50 copay 

Ambulatory Surgical Center (ASC):

• PCP – $15 copay
• Specialist – $50 copay

Outpatient Hospital:

• PCP – $15 copay
• Specialist – $50 copay

Inpatient Hospital:

• 25% of plan allowance

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

Professional services provided in –

• Hospital (inpatient)
• Hospital outpatient department
• Ambulatory surgical center
• Office
• Skilled Nursing

In-network

Office:

• PCP – No copay
• Specialist – $40 copay

Ambulatory Surgical Center (ASC):

• PCP – No copay
• Specialist – $40 copay

Outpatient Hospital:

• PCP – No copay
• Specialist – $40 copay

Inpatient Hospital:

• 20% of plan allowance

Out-of-Network

Office:

•  $80 copay

Ambulatory Surgical Center (ASC):

• $80 copay

Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• 30% of plan allowance

In-network

Office:

• PCP – $15 copay
• Specialist – $50 copay 

Ambulatory Surgical Center (ASC):

• PCP – $15 copay
• Specialist – $50 copay

Outpatient Hospital:

• PCP – $15 copay
• Specialist – $50 copay

Inpatient Hospital:

• 25% of plan allowance

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations;
• General nursing care
• Meals and special diets.

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

In-network:
• 20% of plan allowance

Out-of-network:
• 30% of plan allowance

In-network:
• 25% of plan allowance

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Acute Inpatient Rehabilitation
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.
• Note: Hospitalization solely for Acute Rehabilitation is limited to 90 days per benefit period.

In-network:
• 20% of plan allowance 

Out-of-network:
• 30% of plan allowance 

In-network:
• 25% of plan allowance

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care, except when medically necessary 

All Charges

All Charges

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• Professional services, such as those listed in sections 5 (a), that are the sole service and billed by the hospital.  Examples include, but are not limited to, covered education classes, physical therapy and cardiac rehabilitation.

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

Note: Office visits rendered in a hospital, hospital clinic or health care provider’s office visit on a hospital campus are not subject to the facility copay.

In-network:
• Outpatient Hospital (Non-Surgical): $100 copay 
• Freestanding /Ambulatory Surgical Center: $100 copay
• Outpatient Hospital (Surgical): $150 copay

Out-of-network:
• Outpatient Hospital (Non-Surgical): $150 copay 
• Freestanding /Ambulatory Surgical Center: $150 copay 
• Outpatient Hospital (Surgical): $200 copay
• Non-participating facilities may bill the member for any amount in excess of our allowed benefit.

In-network:
• Outpatient Hospital (Non-Surgical): $50 copay 
• Freestanding /Ambulatory Surgical Center: $150 copay
• Outpatient Hospital (Surgical): $200 copay

Diagnostic Services such as laboratory tests and pathology services such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and EEG

In-Network:

1) Labs: No copay
2) X-Rays: $40 copay
3) Other diagnostic services: $40 copay

Out-of-Network:
1) Labs: 20% of plan allowance 
2) X-Rays: 20% of plan allowance 
3) Other diagnostic services: 20% of plan allowance

In-Network:

1) Labs: $50 copay
2) X-Rays: $100 copay
3) Other diagnostic services: $100 copay

Specialty Imaging:

• MRA/MRS
• MRI
• PET
• CAT scans

In-Network:

$75 copay

Out-of-Network:

20% of plan allowance

In-Network:

$150 copay

If a Plan doctor determines that you need full-time skilled nursing care or need to stay in a skilled nursing facility, and we approve that decision, we will give you the comprehensive range of benefits with no dollar or day limit.

• Bed, board, and general nursing care
• Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor.

In-Network:

• Facility- 20% of plan allowance

Out-of-Network:

• Facility- 30% of plan allowance

In-Network:

• Facility- 25% of plan allowance

   Not covered:

• Custodial care

If terminally ill, you are covered for supportive and palliative care in your home or at a hospice. This includes inpatient and outpatient care and family counseling. A Plan doctor, who certifies that you are in the terminal stages of illness, with a life expectancy of approximately six (6) months or less, will direct these services.

Respite Care is limited to three (3) periods of 48 hours during the Hospice Eligibility Period.

Bereavement Services are provided for up to three (3) visits during the 90 days following the patient’s death.

In-network:

• $40 copay per visit

Out-of-network:

• $80 copay per visit 

In-network:

• No Charge

• Local professional ambulance service when medically appropriate
• Air ambulance service when medically appropriate
• Not covered: Air ambulance, unless medically necessary and no other transport is reasonably available.

In-network:

• $100 copay

Out-of-network:

• $150 copay
• Non-participating providers may bill the member for the amount in excess of our allowed benefit

In-network:

• $200 copay

• Emergency care at an urgent care center
• Emergency care as an outpatient in a hospital, including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

Note: For services within the service area and provided by a nonparticipating provider, the member is not responsible for amounts in excess of the allowed benefits.

Note: If emergency room and treating physician bill separately, both copays will apply

In-Network:

• Emergency Room - $200 copay per visit (waived if admitted)
• Emergency Room Professional Services - $40 copay per visit
• Urgent Care Center - $50 copay per visit

Out-of-Network:

• Emergency Room - $200 copay per visit (waived if admitted)
• Emergency Room Professional Services - $40 copay per visit
• Urgent Care Center - $80 copay per visit

Note: Out-of-Network Emergency Room and Professional Services are paid at the In-network level

In-Network:

• Emergency Room - $275 copay per visit (waived if admitted)
• Emergency Room Professional Services - $50 copay per visit
• Urgent Care Center - $50 copay per visit

Note: Out-of-Network Emergency Room and Professional Services are paid at the In-network level

Professional ambulance service when medically appropriate.

In-network:
 $100 copay per transport

Out-of-network:
• $150 copay
• Non-participating providers may bill the member for the amount in excess of our allowed benefit

In-network:
$200 copay per transport

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists. Services include:

• Outpatient and office medication management
• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy

In-network:

• Inpatient professional - 20% of plan allowance
• Office/Outpatient Professional - No copay

Out-of-network:

• Inpatient professional - 30% of plan allowance
• Office/Outpatient Professional - $80 copay

Note: Member is responsible for any cost between our plan allowance and the provider's billed charges.

In-network:

• Inpatient professional - 25% of plan allowance
• Office - $15 copay
• Outpatient Professional - $50 copay

Note: Member is responsible for any cost between our plan allowance and the provider's billed charges.

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

In-network:

• 20% of plan allowance 

Out-of-network:

• 30% of plan allowance 
• Member is responsible for any cost between our plan allowance and the facility's billed charges. 

In-network:

• 25% of plan allowance 

• Outpatient services provided and billed by a hospital or other covered facility

• Services such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment

Note: Prior authorization is not required for administration of prescription drugs used to treat an opioid use disorder which contain methadone, buprenorphine, or naltrexone, when rendered in the Outpatient Mental Health and Substance Abuse setting

In-network:
$50 copay

Out-of-Network:
$80 copay

In-network:

Facility: $50 copay

• Inpatient admissions not precertified through Case Management
• Care determined not to meet medically accepted levels of care.

The goals of the Alcohol and Drug Addiction Community-Based Program are to:

1) Provide Members with necessary treatments to deliver the best outcomes for their individual clinical circumstances.
2) Provide access to cost effective addiction treatment programs that offer the most up-to-date clinically appropriate standards.
3) Educate Members, PCPs and all stakeholders as to the causes, identification and treatments of addiction.
4) Provide appropriate care in a community setting outside of a hospital or residential setting to enhance sustainable outcomes and lower costs.

Members may receive any of the following services as part of their treatment:

• Assessment
• Intensive Outpatient Program
• Outpatient Detox
• Partial Hospital Program (PHP)
• Individual Therapy
• Group Therapy
• Family Therapy
• Medication Assisted Treatment (MAT)  (includes psychiatrist assessment)

Preferred Recovery Centers can be located at www.member.carefirst.com/mos/#/fadpublic/search/standard

• CareFirst Preferred Addiction Recovery center - No cost share for intensive outpatient treatment program
• Other outpatient recovery centers - Standard out-of-pocket amounts (copay, coinsurance) will apply

• CareFirst Preferred Addiction Recovery center - No cost share for intensive outpatient treatment program
• Other outpatient recovery centers - Standard out-of-pocket amounts (copay, coinsurance) will apply

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered
• Insulin
• Diabetic supplies limited to:  Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction
• Drugs to treat gender dysphoria

Note: Specialty Drugs are typically high in cost and have one or more of the following characteristics:

• Injectable, infused, inhaled, or oral therapeutic agents, or products of biotechnology 
• Complex drug therapy for a chronic or complex condition, and/or high potential for drug adverse effects 
• Specialized patient training on the administration of the drug (including supplies and devices needed for administration) and coordination of care is required prior to drug therapy initiation and/or during therapy 
• Unique patient compliance and safety monitoring requirements 
• Unique requirements for handling, shipping, and storage
• Intravenous fluids and medications for home use, implantable drugs (such as Norplant), some injectable drugs (such as Depo Provera), and IUDs are covered under the Medical and Surgical Benefits
• Specialty drugs require pre-authorization and the use of preferred pharmacies
• Glucometers are covered as Durable Medical Equipment under the Medical and Surgical Benefits. See page (Applies to printed brochure only)
• Specialty drugs are limited to a 34-day supply for the first initial fill

Retail: up to 34-day supply per copay:

Tier 1 generics - No copay
Tier 2 preferred brand - $50 copay
Tier 3 non-preferred brand - $75 copay
Tier 4 preferred specialty - $100 copay
Tier 5 non-preferred specialty - $150 copay

Preferred and non-preferred brand Insulin -$30 copay

Maintenance drugs up to 90-day supply per copay:

Tier 1 generics - No copay
Tier 2 preferred brand - $100 copay
Tier 3 non-preferred brand - $150 copay
Tier 4 preferred specialty - $200 copay
Tier 5 non-preferred specialty - $300 copay

Mandatory Generic Drug Substitution applies to this plan. If your prescriber writes "Dispense as Written" for the brand name drug, and you receive a brand name drug when a Federally approved generic drug is available, you will have to pay the difference in cost between the brand name drug and the generic plus the brand copay.

Out-of-Network: Members will be responsible for all charges for drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies 

There is a $100 Self Only enrollment deductible and $200 Self Plus One and Self and Family enrollments deductible for pharmacy for the Blue Value Plus option on Tiers 2 - Tiers 4

Retail: up to 34-day supply per copay:

Tier 1 Preferred generics - $10 copay, no deductible 
Tier 2 Preferred brand - Deductible, then $50 copay
Tier 3 Preferred specialty generic - Deductible, then $100 copay
Tier 4 preferred specialty brand - Deductible, then $150 copay

Preferred brand Insulin - No deductible, then $30 copay

Maintenance Drugs Up to 90-day supply per copayment:

Tier 1 Preferred generics - $20 copay, no deductible 
Tier 2 Preferred brand - Deductible, then $100 copay
Tier 3 Preferred specialty generic - Deductible, then $200 copay
Tier 4 preferred specialty brand - Deductible, then $300 copay

Preventive Care medications to promote better health as recommended by ACA.

The following drugs and supplements are covered without cost-share, even if over-the-counter, are prescribed by a health care professional and filled at a network pharmacy:

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 mcg & 800 mcg
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6

No Copay

No Copay

Preventive Care medications to promote better health as recommended by ACA includes the following:

• Men and women ages 40 through 75 years old
• No quantity limit
• No prior authorization
• Low to moderate dose statins, generics only (no high dose or brand statins are included)

The following generic drugs are covered without cost-share as prescribed by a health care professional and filled at a network pharmacy and will be made available as follows:

• Atorvastatin 10 mg, 20 mg
• Fluvastatin 20 mg, 40 mg
• Fluvastatin ER 80 mg
• Lovastatin 10 mg, 20 mg, 40 mg
• Pravastatin 10 mg, 20 mg, 40 mg, 80 mg
• Rosuvastatin 5 mg, 10 mg
• Simvastatin 5 mg, 10 mg, 20 mg, 40 mg

Note: For statin prescriptions outside of these age ranges and/or strengths our standard plan benefits will apply.

No copay

No copay

The following prescription drugs are covered in full:

• Chemotherapy medications received through a pharmacy
• Preventive Breast Cancer drugs for women who are at an increased risk for breast cancer, and at a low risk for adverse medication effects

Please refer to our website carefirst.com/fedhmo for any updates to this list and for additional information on how these items are covered.

No copay

No copay

Women's contraceptive drugs and devices 

No copay

No copay

Smoking deterrents

Note: Medications approved by the FDA to treat tobacco dependence are covered under the tobacco and nicotine cessation benefits and dispensed under our pharmacy program.  To be covered, the medications must be prescribed by a physician, even if it is available over-the-counter. 

No charge, up to two (2) attempts per year.

No Charge, up to two (2) attempts per year

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Fertility drugs
• Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies
• Nonprescription medications medicines

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco and nicotine dependence are covered under the Tobacco and nicotine cessation benefit on page (Applies to printed brochure only)

In-network:

• PCP - No copay
• Specialist - $40 copay

Out-of-network:
• $80 copay

In-network:

• PCP - $10 copay
• Specialist - $50 copay

Flexible benefits

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all the following terms in addition to other terms as necessary.  Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process.  (See Section 8).

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all the following terms in addition to other terms as necessary.  Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process.  (See Section 8).

24-hour nurse line

If your PCP is unavailable, call FirstHelp a free nurse advice line available 24 hours a day, 7 days a week.
Call 800-535-9700 to speak to a registered nurse who will discuss your symptoms and recommend the most appropriate care.

If your PCP is unavailable, call FirstHelp a free nurse advice line available 24 hours a day, 7 days a week.
Call 800-535-9700 to speak to a registered nurse who will discuss your symptoms and recommend the most appropriate care.

Services for deaf and hearing impaired

Our TTY number for Customer Service is      (202) 479-3546

Our TTY number for Customer Service is      (202) 479-3546

Care Team Program

We provide programs for members diagnosed with coronary artery disease, congestive heart failure, diabetes, cancer, asthma and other chronic conditions. These programs are designed to help you better understand and manage your condition. Our Care Team Program benefits may include:

• Educational materials, such as self-monitoring charts, resource listings, self-care tips, and a quarterly newsletter
• A health assessment and nurse consultation
• Access to a 24-hour Nurse Advisor help line

Please call us at (800) 783-4582 for more information about our Care Team Program

We provide programs for members diagnosed with coronary artery disease, congestive heart failure, diabetes, cancer, asthma and other chronic conditions. These programs are designed to help you better understand and manage your condition. Our Care Team Program benefits may include:

• Educational materials, such as self-monitoring charts, resource listings, self-care tips, and a quarterly newsletter
• A health assessment and nurse consultation
• Access to a 24-hour Nurse Advisor help line

Please call us at (800) 783-4582 for more information about our Care Team Program

Away from Home Care Program

If you or one of your covered family member move outside of our service area for an extended period of time (for example, if your child goes to college in another state), you may be able to take advantage of our Guest Membership Program. This program would allow you or your dependents the option to utilize the benefits of an affiliated BlueCross BlueShield HMO. Please contact us at (888) 452-6403 for more information on the Guest Membership Program.

If you or one of your covered family member move outside of our service area for an extended period of time (for example, if your child goes to college in another state), you may be able to take advantage of our Guest Membership Program. This program would allow you or your dependents the option to utilize the benefits of an affiliated BlueCross BlueShield HMO. Please contact us at (888) 452-6403 for more information on the Guest Membership Program.

www.carefirst.com/fedhmo Visit our expanded web option

My Account

This tool gives members access to their claims and benefit eligibility information when they log in to the secure, password-protected site.  Each covered member over the age of 14 may create his or her own user ID and password.  After creating a password, members can:

• View who is covered under their contract
• Current and historical claims status
• Order a new ID card

Prescription Drug Benefits section includes information for prospects and members including:

• Formulary List
• HealthyBlue Select Generic List

Additional features include:

• Drug pricing tool
• Hospital comparison tool
• Treatment cost estimator
• Provider Directory with special information
• Health Risk Assessment

My CareFirst

This is our member health and wellness section.   Here you can find:

• Health Library of Medical Conditions
• Health Lifestyle Section-Nutrition, Fitness, etc.
• Personal Health page, with tracking tools and assistance setting health and wellness goals.

My Account

This tool gives members access to their claims and benefit eligibility information when they log in to the secure, password-protected site.  Each covered member over the age of 14 may create his or her own user ID and password.  After creating a password, members can:

• View who is covered under their contract
• Current and historical claims status
• Order a new ID card

Prescription Drug Benefits section includes information for prospects and members including:

• Formulary List
• HealthyBlue Select Generic List

Additional features include:

• Drug pricing tool
• Hospital comparison tool
• Treatment cost estimator
• Provider Directory with special information
• Health Risk Assessment

My CareFirst

This is our member health and wellness section.   Here you can find:

• Health Library of Medical Conditions
• Health Lifestyle Section-Nutrition, Fitness, etc.
• Personal Health page, with tracking tools and assistance setting health and wellness goals.

Telephonic Health Coaching

The healthy lifestyle coaching program fills a void between healthy employees and those who suffer from chronic diseases. Employees who are at high risk for future disease as identified by MyHealth Profile are invited to participate in healthy lifestyle coaching sessions.

These are scheduled phone conversations where employees develop a relationship with a clinician (health coach) trained in Motivational Interviewing and in Behavior Change Theory. The health coach identifies a number of factors including the employee’s existing barriers to change and their readiness to change. The health coach then helps the employee set achievable short-term and long-term goals so they can make a permanent change in health behavior.

The healthy lifestyle coaching program fills a void between healthy employees and those who suffer from chronic diseases. Employees who are at high risk for future disease as identified by MyHealth Profile are invited to participate in healthy lifestyle coaching sessions.

These are scheduled phone conversations where employees develop a relationship with a clinician (health coach) trained in Motivational Interviewing and in Behavior Change Theory. The health coach identifies a number of factors including the employee’s existing barriers to change and their readiness to change. The health coach then helps the employee set achievable short-term and long-term goals so they can make a permanent change in health behavior.

BlueRewards

Financial incentives can effectively encourage Members to take an active role in their own health. Through Blue Rewards - the CareFirst Health and Wellness Incentive Program - Members can earn a reward for completing specific activities that increase the likelihood of success in their wellness efforts.

For 2022, the Blue Rewards incentive program will include Subscribers and Spouses for all CareFirst medical plans to encourage initial and ongoing engagement. Blue Rewards will feature three types of rewards 1) participation-based rewards, 2) ongoing rewards, and 3) coaching rewards: 

Participation Rewards – will be earned by members who complete one or both of the following activities within 120 days of their effective/renewal date:

1. Choose a PCP AND complete their health screening with their PCP or at a CVS MinuteClinic to earn $100 
2. Complete a health assessment AND provide e-consent for wellness communications to earn $50

Ongoing Rewards – will become available once members complete the above step 2:

1. Retaking their health assessment after a 6-month period to earn $50

Coaching Rewards – Members who are identified by CareFirst (coach-directed) and contacted for health coaching, can earn rewards for participating in coaching sessions during their benefit period:

1. Consenting and completing coaching calls (one session per month, maximum three sessions) to earn $30 session 1, $70 session 2, $100 session 3 (maximum of $200 per benefit period).  
2. Members will receive their incentive in the form of a medical expense debit card to help pay for deductibles, copays, and coinsurance for CareFirst health, pharmacy, vision, and dental costs. The debit card reduces barriers to care and is preloaded with Merchant Category Codes (MCC) for eligible medical expenses that dictate whether the card will work at a specific location. If the member tries to use the card at a location where the MCC is not loaded, the card will reject the charge. 

To get started, visit carefirst.com/sharecare. You’ll need to enter your CareFirst account username and password and complete the one-time registration with Sharecare to link your CareFirst account information. This will help personalize your experience.

Financial incentives can effectively encourage Members to take an active role in their own health. Through Blue Rewards - the CareFirst Health and Wellness Incentive Program - Members can earn a reward for completing specific activities that increase the likelihood of success in their wellness efforts.

For 2022, the Blue Rewards incentive program will include Subscribers and Spouses for all CareFirst medical plans to encourage initial and ongoing engagement. Blue Rewards will feature three types of rewards 1) participation-based rewards, 2) ongoing rewards, and 3) coaching rewards: 

Participation Rewards – will be earned by members who complete one or both of the following activities within 120 days of their effective/renewal date:

1. Choose a PCP AND complete their health screening with their PCP or at a CVS MinuteClinic to earn $100 
2. Complete a health assessment AND provide e-consent for wellness communications to earn $50

Ongoing Rewards – will become available once members complete the above step 2:

1. Retaking their health assessment after a 6-month period to earn $50

Coaching Rewards – Members who are identified by CareFirst (coach-directed) and contacted for health coaching, can earn rewards for participating in coaching sessions during their benefit period:

1. Consenting and completing coaching calls (one session per month, maximum three sessions) to earn $30 session 1, $70 session 2, $100 session 3 (maximum of $200 per benefit period).  
2. Members will receive their incentive in the form of a medical expense debit card to help pay for deductibles, copays, and coinsurance for CareFirst health, pharmacy, vision, and dental costs. The debit card reduces barriers to care and is preloaded with Merchant Category Codes (MCC) for eligible medical expenses that dictate whether the card will work at a specific location. If the member tries to use the card at a location where the MCC is not loaded, the card will reject the charge. 

To get started, visit carefirst.com/sharecare. You’ll need to enter your CareFirst account username and password and complete the one-time registration with Sharecare to link your CareFirst account information. This will help personalize your experience.

SmartShopper Program

The SmartShopper incentive and engagement Program is available to Subscribers and Spouses for all CareFirst medical plans. A Member is eligible to participate in the program if they require a specific treatment or procedure as specified by CareFirst.  A Member is able to utilize the SmartShopper Program by means of CareFirst’s integrated digital tool or by calling a designated toll-free number and speaking with a member of the Personal Assistant Team (“PAT”). Members are able to earn rewards for selecting the most cost-effective providers and site of service for care. A Member will receive an incentive for each service or category of Comparable Health Care Service resulting from comparison shopping and there is no limit on the Incentive amount(s) a Member may earn in the benefit period.

The SmartShopper incentive and engagement Program is available to Subscribers and Spouses for all CareFirst medical plans. A Member is eligible to participate in the program if they require a specific treatment or procedure as specified by CareFirst.  A Member is able to utilize the SmartShopper Program by means of CareFirst’s integrated digital tool or by calling a designated toll-free number and speaking with a member of the Personal Assistant Team (“PAT”). Members are able to earn rewards for selecting the most cost-effective providers and site of service for care. A Member will receive an Incentive for each service or category of Comparable Health Care Service resulting from comparison shopping and there is no limit on the Incentive amount(s) a Member may earn in the benefit period.

Routine physical every year which includes screenings, such as:

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/

• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org\

• Individual counseling on prevention and reducing health risks

• Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/

  Note: Genetic Testing: Prior Authorization is required for genetic testing. Ordering providers must obtain authorization for all genetic tests either by accessing the CareFirst provider portal under Pre-Auth / Notifications or calling AIM directly at (844) 377-1277. HLA Typing / Preimplantation (related to in vitro fertilization) may require authorization through the health plan and can be managed in CareFirst’s provider portal under Medical Prior Authorization and no authorization is required for Cologuard®.

In-network:

• No Copay

Out-of-network:

• Calendar year deductible applies
• No Copay
• All costs between the plan allowance and the provider billed charges

• Routine mammogram — covered for women 

In-network:

• No copay

Out-of-network:

• No copay
• When seeing providers who are not contracted with CareFirst BlueCross BlueShield or are not participating in any of our networks, you may be responsible for any amount in excess of our allowed benefit in addition to the appropriate deductible and copay

• Routine exams limited to:
  • One (1) routine eye exam every 12 months
  • One (1) routine OB/GYN exam every 12 months including one (1)Pap smear and related services
  • One (1) routine hearing exam every 24 months

In-network:

• No copay

Out-of-network:

• Calendar year deductible applies
• No copay 
• When seeing providers who are not contracted with CareFirst BlueCross BlueShield or are not participating in any of our networks, you may be responsible for any amount in excess of our allowed benefit in addition to the appropriate deductible and copay

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams or travel.
• Immunizations, boosters, and medications for travel or work-related exposure

• Well-child visits, examinations, and immunizations other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org

• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of  immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html

• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

Note: Any procedure, injection, diagnostic service, laboratory, or x-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

In-network:

• No copay

Out-of-network:

• Calendar year deductible applies
• No copay
• When seeing providers who are not contracted with CareFirst BlueCross BlueShield or are not participating in any of our networks, you may be responsible for any amount in excess of our allowed benefit in addition to the appropriate deductible and copay

Not covered: 

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel
• Immunizations, boosters, and medications for travel

All charges

Preventive care limited to:

• Prophylaxis (cleaning of teeth) – limited to two (2) treatments per calendar year
• Fluoride applications (limited to one (1) treatment per calendar year and for children under age 16)
• Sealants – (once every three (3) years, from the last date of service, on permanent molars for children under age 16)
• Space maintainer (primary teeth only)
• Bitewing X-rays (one (1) set per calendar year)
• Complete series X-rays (one (1) complete series every three (3) years)
• Periapical X-rays
• Routine oral evaluations (limited to two (2) per calendar year)

The deductible applies to almost all benefits in this Section.  In the You pay column, we say “No deductible” when it does not apply.  When you receive covered services from network providers, you are responsible for paying the allowable charges until you meet the deductible. 

100% of allowable charges until you meet the deductible of  $1,400 per Self Only enrollment, $2,800 per Self Plus One enrollment and Self and Family enrollment for in-network services and $3,000 per Self Only, and $6,000 per Self Plus One and Self and Family for out-of-network care.

In-network:  After you meet the deductible, you pay the indicated coinsurance or copayments for covered services.  You may choose to pay the coinsurance and copayments from your HSA or HRA, or you can pay for them out-of-pocket.

Out-of-network:  After you meet the deductible, you pay the indicated coinsurance or copayments based on our Plan allowance and any difference between our allowance and the billed amount.

Professional services of physicians:

• In physician’s office
• Inpatient/Skilled nursing Professional (Non-Surgical)
• Outpatient Professional (Non-Surgical)
• Office medical consultations
• Second surgical opinion

Office/Outpatient Hospital

In-network:

• PCP - No copay
• Specialist - $35 copay

Out-of-network: 

• $80 copay

Note: Office visits rendered in a hospital, hospital clinic or health care provider’s office visit on a hospital campus are not subject to the facility copay.

Inpatient Hospital/Skilled Nursing

In-network:

• Deductible, then 20% of plan allowance

 Out-of-network:

• Deductible, then 30% of plan allowance 

Convenience care (Retail health clinic):

While primary care providers should be the first line of defense for members, there are tiered care alternatives members can access when their PCP is not available such as CVS MinuteClinic, Walgreens TakeCare and Target Clinic who can serve as the immediate backup to PCPs (after hours).

In-network: Deductible, then $0 copay

Out-of-network: Deductible, then $80 copay

Telemedicine Services/CareFirst Video Visits:

• Benefits are available to the same extent as benefits provided for other services.
• Example:
  • If services are rendered by a PCP, the member would be responsible for the PCP cost-share.
  • If services are rendered by a Specialist, the member would be responsible for the Specialist cost-share. 

Note: Members have a 24/7 access to on-demand video consultations with board certified physicians with CareFirst Video Visit. 

Please visit: www.Carefirstvideovisit.com 

Benefits are available to the same extent as benefits provided for other services

Tests, such as: 

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and EEG

Office/Freestanding Setting

In-Network:

• Labs: Deductible then, no copay
• X-Rays: Deductible then, $35
• Other diagnostic services: Deductible then, $35

Out-of-Network:

• Labs: Deductible then, 20% of plan allowance
• X-Rays: Deductible then, 20% of plan allowance
• Other diagnostic services: Deductible then, 20% of plan allowance

Specialty Imaging:

• MRA/MRS
• MRI
• PET
• CT/CAT scans

In-Network:

Deductible then, $75

Out-of-Network:

Deductible then, 20% of plan allowance

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes for pregnant women after 24 weeks gestation
• Delivery
• Postnatal care

Members are responsible for both physician and facility fees. Please refer to section 5(c) for outpatient or inpatient facility fees.

1. Preventive Services

a) Preventive outpatient obstetrical care of an uncomplicated pregnancy, including prenatal evaluation and management office visits and one postpartum office visit;

b) Prenatal laboratory tests and diagnostic services related to the outpatient care of an uncomplicated pregnancy, including those identified in the current recommendations of the United States Preventive Services Task Force that have in effect a rating of "A" or "B" or provided in the comprehensive guidelines for women's preventive health supported by the Health Resources and Services Administration;

c) Preventive laboratory tests and services rendered to a newborn during a covered hospitalization for delivery, identified in the current recommendations of the United States Preventive Services Task Force that have in effect a rating of "A" or "B", the Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care, and the Uniform Panel of the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children, including the collection of adequate samples for hereditary and metabolic newborn screening and newborn hearing screening; and

d) Breastfeeding support, supplies and consultation. 

2. Non-Preventive Services

a) Outpatient obstetrical care and professional services for all prenatal and post-partum complications, including prenatal and post-partum office visits.

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see page  for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity  stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

b) Birthing classes, one course per pregnancy, at a CareFirst BlueChoice approved facility.

3. Professional Services at Delivery - Professional services are covered under Section 5(a). 

In-network:

• Preventive - No Charge
• Non-Preventive - Deductible, then no charge
• Professional Services at Delivery - Deductible, then 20% of plan allowance

Out-of-network:

• Preventive - Deductible, then no charge
• Non-Preventive - Deductible, then no charge
• Professional Services at Delivery - Deductible, then 30% of plan allowance

 Not covered:

• Doulas

All Charges

In-network:

• No copay, deductible does not apply

Out-of-network:

• $80 copay

A range of voluntary family planning services, limited to:

• Voluntary sterilization for a woman
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo-Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit

In-network:

• No copay – deductible does not apply

Out-of-network:

• $80 copay

Voluntary sterilization for a male:

Hospital services are covered under Section 5(c). Surgical benefits are covered under Section 5(b).

Deductible applies:

In-network:

• Professional copay of $35

Out-of-network:

• $80 copay

Note: Facility copays are in Section 5(c).

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic counseling
• Elective Abortion

Diagnosis and treatment of infertility such as:

• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Fertility drugs for covered procedures

Note:

• We cover drugs for the treatment of infertility, unless they are prescribed for procedures not covered under this plan.  When covered, injectable drugs are medical benefits, and oral drugs are benefits under prescription drug coverage.  See Section 5(g).
• Prior authorization for the treatment must be obtained from CareFirst BlueChoice.
• Benefits are limited to six (6) attempts per live birth.
• Any charges associated with the collection of the sperm will not be covered unless the partner is also a member.
• The member is responsible for the copayment or coinsurance for artificial insemination stated in the Schedule of Benefits.
• Coverage is subject to the exclusions listed in the Exclusions and Limitations Section at the end of this Description of Covered Services.
• Procedure is covered regardless of whether the couple has a relationship under which the FEHB Program recognizes each partner as a spouse of the other.
• Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

In-network:

• $35 office copay

Out-of-network:

• $80 copay

Iatrogenic infertility

Standard Fertility Preservation for members who have been diagnosed with Iatrogenic Infertility:

• the collection of sperm
• cryopreservation of sperm
• collection of embryo
• cryopreservation of embryo
• collection of oocyte
• cryopreservation of oocyte
• benefits limited to up to 12 months of storage of sperm, oocytes and embryo

Prior authorization for the treatment must be obtained from CareFirst BlueChoice.

Benefits are limited to six (6) attempts per live birth.

In-network:

• deductible then, $35 office copay

Out-of-network:

• deductible then, $80 copay

Members are responsible for both physician

and facility fees. Please refer to Section 5(c)

for outpatient or inpatient facility fees.

Not covered:

• In vitro fertilization (IVF)
• Embryo transfer and gamete intra-fallopian transfer (GIFT)
• Zygote intra-fallopian transfer (ZIFT)
• Intrauterine and Assisted reproductive technology (ART) procedures, such as:
  • Services and supplies related to ART procedures
  • Cost of donor sperm
  • Cost of donor egg
  • Drugs for non-covered procedure

• Testing and treatment
• Allergy injections

Note:  If there is a charge for the injection and not the office visit, the office copay will still apply.

In-network:

• $35 office copay

Out-of-network:

• $80 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

Allergy serum

No charge

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees

• Radiation therapy
• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Growth hormone therapy (GHT)

Note:  Growth hormone is covered under the prescription drug benefit.

Note: We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary. 

In-network:

• $35 office copay

Out-of network:

• $80 copay

Note: Members are responsible for both physician and facility fees. Please refer to section 5(c) for outpatient or inpatient facility fees.

Up to 60 visits (combined physical, occupational and/or speech therapy) per condition per benefit period for the services of the following qualified providers:

• Physical therapists
• Occupational therapists
• Speech therapists

Note: Coverage shall include Physical Therapy, Occupational Therapy and Speech Therapy for the treatment of individuals who have sustained an illness or injury that CareFirst BlueChoice determines to be subject to improvement

Note: Occupational Therapy is limited to the use of purposeful activity or interventions designed to achieve functional outcomes that promote health, prevent injury or disability, and that develop, improve, sustain or restore the highest possible level of independence of an individual.

Note: Other than any applicable inpatient or outpatient facility copay, member has no copay or coinsurance during an approved inpatient stay.

Note: Members are responsible for both physician and facility fees. Please refer to section 5(c) for outpatient or inpatient facility fees.

In-network:

• $35 office copay

Out-of-network:

• $80 copay

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• Maintenance therapy

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to 90 sessions per condition per benefit period.

• Cardiac rehabilitation benefits are provided to members who:
  • have been diagnosed with a significant cardiac disease
  • suffered a myocardial infarction
  • undergone invasive cardiac treatment immediately preceding referral

Note: Members are responsible for both physician and facility fees. Please refer to section 5(c) for outpatient or inpatient facility fees.

In-network:

• $35 office copay

Out-of-network:

• $80 copay

Not Covered:

• Benefits are not provided for maintenance cardiac rehabilitation.

All charges

Pulmonary Rehabilitation

• For those who have significant pulmonary disease or who have undergone certain surgical procedures of the lung.
• Limited to one (1) pulmonary rehabilitation program per lifetime.
• Benefits are not provided for maintenance programs

Note: Members are responsible for both physician and facility fees. Please refer to section 5(c) for outpatient or inpatient facility fees.

In-network:

• $35 office copay

Out-of-network:

• $80 copay

• Habilitative Services are services, including Occupational Therapy, Physical Therapy, and Speech Therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child's ability to function.
• Benefits are subject to the applicable Occupational Therapy, Physical Therapy, and Speech Therapy copay but are not counted toward any visit maximum for therapy services.
• Habilitative Therapy ABA coverage for Applied Behavioral Analysis include Verbal Behavior therapy, Occupation Therapy, Physical Therapy and Speech Therapy from 18 months to 21 years of age. There will be no visit maximums and preauthorization will be required.
• Note: Members are responsible for both physician and facility fees. Please refer to section 5(c) for outpatient facility fees

In-network:

• Deductible, then $35

Out-of-network:

• Deductible, then $80 copay

Not covered:

• Benefits delivered through early intervention or school services

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist
• Member is responsible for getting approval for all out-of-network services

Note: For routine hearing screening performed during a child’s preventive care visit, see Section 5(a), Preventive care, children.

In-network:

• $35 per visit

Out-of-network:

• $80 copay

• External hearing aids

Note: For medical devices, such as bone anchored hearing aids (BAHA) and cochlear implants, (that or which) are surgically implanted see  Orthopedic and prosthetic supplies. For more information on benefits, see Section 5(a) Orthopedic and prosthetic devices.

In-network: 

• 15% of Plan Allowance                                                                                                        

Note: Limited to $1,500 payment per ear per 36 months

Out-of-network:

• 15% of Plan Allowance                                                                                                       

Note: Limited to $1,500 payment per ear per 36 months

Provider may bill any amount in excess of our plan allowance. Participating providers will advise you in writing in advance if you will have a balance.

Not covered: 

• Hearing services that are not shown as covered

Medical Vision Services

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)
• Annual eye refractions
• Medical eye exams

Note: This is a medical benefit not a vision benefit.

In-network:

• Specialist-$35 copay

Out-of-network:

• $80 copay

Routine eye exams
Note: See Preventive care, children for eye exams for children
Note: Eye care and exams related to medical conditions are subject to the specialist copay

In-network:
• $10 per visit at Davis Vision Providers

Out-of-network:
• All charges above $33

Not covered:

• Eyeglasses or contact lenses (except as listed above)
• Eye exercises and orthoptics
• Eyeglasses, contact lenses, routine eye examinations, or vision testing for the prescribing or fitting of eyeglasses or contact lenses
• Deluxe eyeglass frames or lens features for eyeglasses or contact lenses such as special coating, polarization, UV treatment, etc.
• Multifocal, accommodating, toric, or other premium intraocular lenses (IOLs) including Crystalens, ReStor, and ReZoom
• Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia and strabismus as described above
• LASIK, INTACS, radial keratotomy, and other refractive surgery and/or other refractive surgical services 
• Refractions, including those performed during an eye examination related to a specific medical condition

In-network:

• $35 copay

Out-of-network:

• $80 copay

Note: Members are responsible for both physician and facility fees. Please refer to Section 5(c) for outpatient or inpatient facility fees.

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome. 
• Hair Prosthesis (wig) is covered when prescribed by a treating oncologist and the hair loss is the result of chemotherapy. The Plan will cover up to $350 for one (1)  hair prosthesis per benefit period. 
• External hearing aids (See Hearing services in this section for additional information)
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.
• Medically Necessary molded foot orthotics

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical and anesthesia services.  For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

Note:  Externally worn prosthetics and devices are treated as Durable medical Equipment (DME).  See page 111.

In-network:

•  Deductible, then 25% of plan allowance

Out-of-network:

• Deductible, then 25% of plan allowance

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Prosthetic replacements provided less than 3 years after the last one we covered
• Over-the-counter orthotics

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Audible prescription reading devices
• Speech generating devices
• Blood glucose monitors
• Insulin pumps
• Canes
• Diabetic shoes
• Commodes
• Suction machines
• Medical supplies (i.e. ostomy and catheter supplies, dialysis supplies, medical foods for inherited metabolic diseases and Inborn Errors of Metabolism (IEM)
• Externally worn non-surgical durable devices which replace a body part or assist a patient in performing a bodily function (unless otherwise described in the “orthopedic and prosthetic devices” section above)
• Externally worn braces which improve the function of a limb
• Medically necessary fitted compression stockings