Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other plans’ brochures and other materials you need to make an informed decision about your FEHB coverage.  These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, disability leave, pensions, etc. you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request enrollee to verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.  

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLE's visit the FEHB website at www.opm.gov/health-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000.  This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM;
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM

As long as the court/administrative order is in effect, and you have at least one (1) child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your child(ren) live, unless you provide documentation that you have other coverage for the child(ren).

If the court/administrative order is still in effect when you retire, and you have at least one (1) child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect.  Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective January 1, 2024. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1.  If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2024 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2024 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five (5) years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment, or
• You are a family member no longer eligible for coverage including dependents that turn 26. 

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy). 

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM's website at
www.opm.gov/healthcare-insurance/healthcare/plan-information/. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment. 

If you leave Federal service, Tribal employment or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC.  Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage. 

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage. 

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at (888) 789-9065 or visit our website at 
www.carefirst.com/fedhmo.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us toll free at (888) 789-9065 or write to us at Mail Administrator, P.O. Box 14114, Lexington, KY 40512-4114.

You get care from "Plan providers" and "Plan facilities". You will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies) if you use BlueChoice providers under both the Blue Value Plus and BlueChoice options.  If you use the point-of-service feature under BlueChoice, you can also get care from providers in other CareFirst networks as well as non-participating providers. Under BlueChoice, this will cost you more than using our BlueChoice network. Under both Blue Value Plus  and BlueChoice, you are not required to obtain a referral from your primary care provider or another participating physician in our network. You are still responsible for choosing a primary care provider and returning the Selection Form to us or notifying Member Services at (888) 789-9065 of your selection.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached at (888) 789-9065, or on our website at www.carefirst.com/fedhmo for assistance.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website.

FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

It depends on the type of care you need. First, you and each family member must choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your health care. Each member may choose their primary care provider from our provider directory available on our website,
www.carefirst.com/fedhmo.

Your primary care provider can be a family practitioner, general practitioner, internist, or pediatrician. Your primary care provider will provide or coordinate most of your healthcare.

If you want to change primary care providers or if your primary care provider leaves the plan, call us. We will help you select a new one.

Your primary care provider may refer you to a specialist for needed care or you may go directly to a specialist without a referral. Under BlueChoice, you may use other providers, but out-of-network coverage levels will apply.

Here are some other things you should know about specialty care:

• Your primary care provider will create your treatment plan.  The physician may have to get an authorization or approval from us beforehand.  If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. If they decide to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. While BlueChoice provides out-of-network benefits with higher out-of-pocket, our Open Access plan generally will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another in-network specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else. Under BlueChoice, you may continue to see your current specialist, or see any out-of-network specialist, but your care would be paid at the out-of-network level.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause; or
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our service area and you enroll in another FEHB plan, you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change and have in-network benefits apply. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist  at the in-network level until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (toll free) (888) 789-9065.  If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center; or
• the day your benefits from your former plan run out; or
• the 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

Since your primary care provider arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

Your primary care provider has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. You must obtain prior approval for:

• Dialysis in a hospital setting
• Growth hormone therapy (GHT)
• Home health care
• Hospice care
• Outpatient services
• Non-routine maternity admission rendered outside of the CareFirst Service Area and/or by out-of- network non-participating providers require precertification under BlueChoice
• Skilled nursing facility
• Specialty drugs
• Organ and Tissue Transplants
• Genetic Testing
• Sleep Studies (except non-attended)
• Air Ambulance Services
• Specialized Radiation Therapy
• Artificial Insemination Infertility Treatments and fertility drugs
• Habilitative and Applied Behavioral Analysis (ABA)
• Inpatient and outpatient hospital Electroconvulsive Therapy (ECT)
• Repetitive Transcranial Magnetic Stimulation (TMS)
• Inpatient Behavioral Health and Substance Use Disorder
• Residential Treatment Centers (RTC)

• See https://provider.carefirst.com/providers/medical/in-network-precertification-preauthorization.page for a list of specific Covered Services which require prior authorization

First, your physician, your hospital, you, or your representative, must call us at (866) 773-2884 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility: and
• number of days requested for hospital stay.

Blue Value Plus

Prior authorization is required for all In-Network outpatient services performed in the outpatient department of a hospital, including but not limited to, outpatient surgery, specialty imaging, diagnostic, laboratory and X-ray services, Outpatient Rehabilitative Services and Infusion Services.

Benefits will not be approved at these locations if CareFirst BlueChoice determines that the procedure can be provided in a medically appropriate manner within a physician's office or other less intensive and less costly setting.

If prior authorization is not obtained, benefits for outpatient services performed in the outpatient department of a hospital are not covered. Prior authorization for in-network services is the responsibility of the in-network provider and a member cannot be held liable when an in-network provider fails to obtain prior authorization.

BlueChoice Standard

Prior authorization is required for all In-Network outpatient services performed in the outpatient department of a hospital, including but not limited to, outpatient surgery, specialty imaging, diagnostic, laboratory and X-ray services, Outpatient Rehabilitative Services and Infusion Services.

Benefits will not be approved at these locations if CareFirst BlueChoice determines that the procedure can be provided in a medically appropriate manner within a physician's office or other less intensive and less costly setting.

If prior authorization is not obtained, benefits for outpatient services performed in the outpatient department of a hospital are not covered. Prior authorization for in-network services is the responsibility of the in-network provider and a member cannot be held liable when an in-network provider fails to obtain prior authorization.

Out-of-network participating providers will also obtain prior authorization for out-of-network covered services for which prior authorization is required. For purposes of this Evidence of Coverage, out-of-network participating provider means any physician, health care professional or health care facility located in the CareFirst BlueChoice Service Area and has contracted with CareFirst BlueCross Blue Shield to be paid directly for rendering Covered Services to Members. Members may obtain out-of-network benefits from out-of-network participating providers.

BlueChoice Advantage Plan:

Prior authorization from CareFirst BlueChoice will be obtained by in-network providers and out-of-network participating providers located in the CareFirst BlueChoice Service Area. If these providers fail to obtain prior authorization, the Member shall be held harmless. Except for Urgent Care, Emergency Services and follow-up care after emergency surgery, it is the Member’s responsibility to obtain prior authorization for (1) Medical Devices and Supplies for In-Network Covered Services, (2) when services are rendered outside of the CareFirst BlueChoice Service Area and (3) for services rendered by out-of-network non-participating providers.

Failure of the Member to meet the utilization management requirements or to obtain prior authorization for services listed in (1), (2) or (3) above, may result in a reduction or denial of the Member’s benefits even if the services are Medically Necessary. Refer to the Schedule of Benefits to determine the Utilization Management Non-Compliance penalty.

You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, 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.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent lay person that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at  (888) 789-9065.  You may also call OPM's FEHB 3 at (202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simulation review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at (888) 789-9065.  If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). 

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. 

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two (2) business days following the day of the emergency admission, even if you have been discharged from the hospital. 

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

Under our BlueChoice option, certain services can be obtained from out-of-network providers.  For services requiring prior authorization or pre-certification, refer to  the "You need prior Plan approval for certain services" section. 

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call (888) 789-9065.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay, or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
   • You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 days.
   • If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.
3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim if you do not agree with our decision you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: When you see your primary care provider, under the Open Access option, you pay a copayment of $25 per office visit, and when you go in the hospital, under the Open Access option, you pay a copayment of $200 per admission.

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for those services. 

The Standard BlueChoice does not have a deductible for medical or pharmacy. 

The Blue Value Plus Option has no medical deductible. There is a $100 deductible for Self and $200 for Self Plus One and Self and Family for Tier 2-5 prescription drugs under the Blue Value Plus Option.

Under the Self Only, Self Plus One, and Self and Family enrollments, services for any or all members contribute to the deductible.  Those services subject to the deductible are indicated in Sections 5(a) through 5(g). 

The BlueChoice Advantage HDHP has a deductible of $1,600 for Self Only enrollment or $3,200 for Self Plus One and Self and Family enrollment for in-network services and $3,200 for Self Only enrollment and $6,400 for Self Plus One and Self and Family enrollment for out-of-network care each calendar year. Individual Coverage: The member must satisfy the individual deductible. Self Plus One and family coverage: The deductible may be met entirely by one member or by combining eligible expenses of two or more covered family members.  There is no individual deductible with family coverage. The family deductible must be reached before CareFirst pays benefits for covered services subject to the deductible for any member who has family coverage. The deductible applies to all benefits excluding all preventive services. Only CareFirst allowable charges are applicable to the deductible.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan option between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

Coinsurance is the percentage of our allowed benefit that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible.

Example: In our Plan, you pay 25% of our allowed benefit for durable medical equipment.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills. 

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.carefirst.com/fedhmo or contact the health plan at (888) 789-9065.

Our "allowed benefit" is the amount we use to calculate our payment for certain types of covered services.  Plans arrive at their allowances in different ways, so they may vary.  For information on how we determine our allowed benefit, see the definition of allowed benefit in Section 10.

Often, the provider's bill is more than our allowed benefit.  It is possible for a provider's bill to exceed the allowance by a significant amount. Whether or not you have to pay the difference will depend on the type of provider you use. BlueChoice has a network of providers who will always accept our allowed benefit. Under our Standard and HDHP BlueChoice options, there are other providers contracted with CareFirst who will only bill you for the amount attributed to the deductible or the appropriate copayment or coinsurance.  Please check the Hearing Aid benefit for detail for when network providers may bill for balances (See page (Applies to printed brochure only) and page (Applies to printed brochure only))

Under BlueChoice, non-participating providers who provide out-of-network services will bill you for any balances in excess of our allowance for covered services in addition to the appropriate deductible, copayment or coinsurance amount.

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

Under Standard BlueChoice, once your expenses for in-network care (co-payment and coinsurance) total $5,000 for Self Only enrollment or $10,000 for Self Plus One and Self and Family enrollment in any calendar year you do not have to pay anymore for covered services.  All covered in-network care counts toward the catastrophic limit. The catastrophic limit for out-of network care is $8,500 for Self Only enrollment and $18,000 for Self Plus One and Self and Family enrollment in any calendar year, and only expenses up to our allowed benefit contribute; any balances in excess of our allowed benefit does not contribute to the catastrophic limit and remain your liability. Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

Under Blue Value Plus, once your expenses for in-network care (coinsurance, co-payments and deductible) total $6,000 for Self Only enrollment or $12,000 for Self Plus One and Self and Family enrollment in any calendar year you do not have to pay anymore for covered services.  All covered in-network care counts toward the catastrophic limit. Only expenses up to our allowed benefit contribute; any balances in excess of our allowed benefit does not contribute to the catastrophic limit and remain your liability. Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

Under the BlueChoice Advantage HDHP option, once your expenses for in-network services are met (coinsurance, copayments and deductible) totaling $5,000 for Self Only enrollment or $10,000 for Self Plus One and Self and Family enrollment in any calendar year), you do not have to pay any more for covered in-network services.  All covered in-network care counts toward the catastrophic limit. The catastrophic limit for out-of network care is $7,000 for Self Only enrollment and $14,000 for Self Plus One and Self and Family enrollment in any calendar year, and only expenses up to our allowed benefit contribute; any balances in excess of our allowed benefit does not contribute to the catastrophic limit and remain your liability.

Please note that the out-of-pocket maximums will be combined for both in-network and out-of-network services for the Standard BlueChoice and HDHP BlueChoice Advantage options.

Out-Of-Pocket Maximum 

• Individual Coverage:
  • The member must meet the individual out-of-pocket maximum.

• Family Coverage:

  • Each member can satisfy their own individual out-of-pocket maximum by meeting the individual out-of-pocket maximum. In addition, eligible expenses of all covered family members can be combined to satisfy the Self and Family out-of-pocket maximum.
  • An individual family member cannot contribute more than the individual out-of-pocket maximum toward meeting the Self and Family out-of-pocket maximum
• Once the Self and Family out-of-pocket maximum has been met, this will satisfy the out-of-pocket maximum for all family members.

These amounts apply to the out-of-pocket maximum:

• Co-payments and coinsurance for all covered services
• Prescription drug benefit Rider co-payments and coinsurance for all covered services
• Deductible

Note: When the member has reached the out-of-pocket maximum, no further co-payments, coinsurance or deductible will be required in that benefit period for covered services. The in-network and out-of-network out-of-pocket maximum contributes towards one another. 

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note:  If you change options in this Plan year, we will credit the amount of covered expenses already accumulated in the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

• Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

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

CloseKnit, provides virtual only primary care services through a dedicated care team of physicians, nurse practitioners, physician assistants, licensed professional counselors and licensed clinical social workers

• Well care / Annual Wellness
• Preventative care
• Urgent Care
• Lifestyle support
• Chronic condition prevention and management
• Medication management
• Clinical educational support
• Behavioral Health and mental health support through professional counselors
• Care Coordination, including ongoing assistance with care activities such as arranging appointments with specialists, refiling prescriptions, etc.

In-network:

• No copay

In-network:

• No copay

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 - $40 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 physicals allowed once per benefit period including 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/Tdap, 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/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women 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 preventive care benefits for women go to 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

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.

Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities.

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/Tdap, 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/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

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 and Postpartum care
• Screening for gestational diabetes 
• Delivery
• Screening and counseling for prenatal and postpartum depression

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

• Preventive Services:
  • Preventive outpatient obstetrical care of an uncomplicated pregnancy, including prenatal evaluation and management office visits and one postpartum office visit;
  • 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;
  • 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
• Non-Preventive Services:
  • 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.
  • Birthing classes, one course per pregnancy, at a CareFirst BlueChoice approved facility;

Note: Members enrolled in the High-Risk OB Care Management Program may be eligible to receive a home blood pressure cuff.

• 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

Not covered:
• Doulas

All Charges

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 supplies in conjunction with each birth. These benefits begin immediately following delivery.

Note: Breast pumps are available pre or post-natal. 

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

Male Voluntary Sterilization

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

In-network:
• No copay

Out-of-network:
• No copay

In-network:
• No copay

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic counseling
• Fertility drugs that are not deemed medically necessary
• Elective Abortion

FDA Approved Fertility Apps

In-network:
• No copay
Out-of-network:
• No copay

In-network:
• No copay

Diagnosis and treatment of infertility specific to:

• Artificial insemination:
  • Intravaginal Insemination (IVI)
  • Intracervical Insemination (ICI)
  • Intrauterine Insemination (IUI)
• Fertility drugs (See Section 5f)

Note:

• We cover drugs for the treatment of infertility, when deemed medically necessary. 
• When covered for artificial insemination, injectable drugs are medical benefits, and oral drugs are benefits under prescription drug coverage. See Section 5(f).
• Prior authorization for the treatment must be obtained from CareFirst BlueChoice.
• Benefits are limited to three (3) attempts per benefit period.
• 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 General Exclusions in Section 6 and the Not Covered section at the end of this Description of 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.
• Infertility is the inability to conceive or produce conception after 1 year of unprotected sex when an individual is under 35 years of age, or 6 months for an individual age 35 or older or failed attempts at artificial insemination. There are various reproductive treatments available for people facing infertility, which are customized according to their medical history and diagnostic results.

In-network:

• 50% coinsurance

Out-of-network:

• 50% coinsurance

In-network:

• 50% coinsurance

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 three (3) attempts per live birth. If a live birth occurs within the 3 attempts the benefit renews. If the member has 3 failed attempts, the benefit is exhausted for the lifetime of the coverage even if the member switches plans the exhausted benefit does not renew.

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.

In-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:

• In vitro fertilization (IVF) medical procedures. See Section 5(f) for In vitro fertilization (IVF) drug

• 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

• 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:

• $40 office copay

Out-of-network:

• $80 office copay

In-network:

• $50 office 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:

• $40 office copay

Out-of-network:

• $80 office 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:

• $50 office 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:

• $40 office copay

Out-of-network:

• $80 office copay

In-network:

• $50 office 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:

• $40 office copay

Out-of-network:

• $80 office copay

In-network:

• $50 office 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:

• $40 office copay

Out-of-network:

• $80 office copay

In-network:

• $50 office copay

Hearing Aids

• Medically necessary external hearing aid is covered up to our plan allowance every 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:
• 25% of Plan Allowance

Out-of-network:
• 25% of Plan Allowance

Limited to $3,000 combined in and out of network payment 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:

• 25% of the plan allowance

Limited to $2,000 payment 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:

• $40 office copay 

Out-of-network:

• $80 office copay

In-network:

• $50 office 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 medical conditions as outlined in the CareFirst Medical Policy.
• 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:

• $40 office copay

Out-of-network:

• $80 office 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:

• $50 office 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-by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner

Limited to 20 visits per Benefit Period.

In-network:

• $40 office copay

Out-of-network:

• $80 office 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:

• $50 office 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.
• Multicomponent, family centered programs focused on childhood obesity that are part of intensive behavioral interventions (behavior change counseling for healthy diet and physical activity)
• 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 the prior authorizations for 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 severe obesity (bariatric surgery)

Note: You must meet certain criteria to be eligible for bariatric surgery. Please see CareFirst's Medical Policy for the criteria
www.provider.carefirst.com/providers/medical/medical-policy.page.

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 affirming 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 affirming 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 and Clinic Visit): $100 copay
• Freestanding /Ambulatory Surgical Center: $100 copay
• Outpatient Hospital (Surgical): $150 copay

Out-of-network:

• Outpatient Hospital (Non-Surgical and Clinic Visit): $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 and Clinic Visit): $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.
• The in-network cost-share will now be applied to approved out-of-network air ambulance. Members cannot be balanced billed.
• 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.
• Air ambulance, when medically necessary.
• The in-network cost-share will now be applied to approved out-of-network air ambulance. Members cannot be balanced billed.

Note: See 5(c) for non-emergency service.

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

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 
https://member.carefirst.com/members/health-wellness/staying-healthy/addiction-program.page

• 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
  • The following drug classes are typically used for gender dysphoria and are covered regardless of gender designation:
    • Progestins
    • Gonadotropin-Releasing Hormone Agonists
    • Aldosterone Antagonists, Selective
    • Antineoplastics, Antiandrogens
    • Oral Contraceptives
    • Estrogen Derivatives
    • Androgens             

• Drugs for anti-obesity based on medical necessity and require prior authorization
• IVF drugs based on medical necessity and require prior authorization

Note: Infertility is the inability to conceive or produce conception after 1 year of unprotected sex when an individual is under 35 years of age, or 6 months for an individual age 35 or older or failed attempts at artificial insemination. There are various reproductive treatments available for people facing infertility, which are customized according to their medical history and diagnostic results.

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:

For a complete list of medications go to the U.S. Preventive Services Task Force (USPSTF) website at www.uspreventiveservicestaskforce.org.

Note: To receive this benefit a prescription from a doctor must be presented to pharmacy.

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

No copay

No copay

Contraceptive drugs and devices as listed in the https://aspe.hhs.gov/sites/default/files/documents/786fa55a84e7e3833961933124d70dd2/preventive-services-ib-2022.pdf site.

Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below. 

• Preventive Services Contraceptive Zero Copay Exception criteria is intended to allow the member to receive a $0 member cost share for any Health Care Reform preventive services contraceptive product not already covered at a $0 member cost share when determined to be medically necessary. To request the exception your provider should contact CVS directly via phone or fax the Exception Request Form. 

• Reimbursement for over-the-counter contraceptives can be submitted by following the instructions on the Prescription Reimbursement Claim Form found here https://www.caremark.com/portal/asset/Carefirst_paperclaim_english.pdf

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 that are not deemed medically necessary
• Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies
• Nonprescription medications unless specifically indicated elsewhere

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 their 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
• BlueChoice 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 their 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
• BlueChoice 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 2024, the Blue Rewards incentive program will include Subscribers and Spouse/Domestic Partners 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:
Both you and your spouse/domestic partner will be rewarded for completing one, or all of the following activities:

1. Choose a PCP AND complete their health screening with your PCP or at a CVS MinuteClinic to earn $100. You must complete within 180 days of your effective date.
2. Complete a health assessment AND provide consent to receive wellness related communications (emails) to earn $50. You must complete within 180 days of your effective date.
3. Retake by updating/confirming responses to your health assessment. Answers must be updated or confirmed no earlier than 90 days after the original assessment, and before the end of the benefit period to earn $50.
4. Participate in Health Coaching Sessions. You may earn rewards for completing one (1), two (2), or three (3) coaching sessions. Completing coaching sessions are based on member participation and not dependent on achieving an outcome and/or health- related goal. Only one (1) coaching session per 2-60 days will count towards an incentive. Members will earn $30 for coaching session one, $70 for coaching session two, and $100 for coaching session three. A maximum of three (3) coaching sessions per Benefit Period will count towards the incentive.

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/wellbeing. You’ll need to complete the one-time registration 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 2024, the Blue Rewards incentive program will include Subscribers and Spouse/Domestic Partners 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:
Both you and your spouse/domestic partner will be rewarded for completing one, or all of the following activities:

1. Choose a PCP AND complete their health screening with your PCP or at a CVS MinuteClinic to earn $100. You must complete within 180 days of your effective date.
2. Complete a health assessment AND provide consent to receive wellness related communications (emails) to earn $50. You must complete within 180 days of your effective date.
3. Retake by updating/confirming responses to your health assessment. Answers must be updated or confirmed no earlier than 90 days after the original assessment, and before the end of the benefit period to earn $50.
4. Participate in Health Coaching Sessions. You may earn rewards for completing one (1), two (2), or three (3) coaching sessions. Completing coaching sessions are based on member participation and not dependent on achieving an outcome and/or health- related goal. Only one (1) coaching session per 2-60 days will count towards an incentive. A maximum of three (3) coaching sessions per Benefit Period will count towards the incentive.

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 www.carefirst.com/wellbeing. You’ll need to complete the one-time registration 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 888-345-2873 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 888-345-2873 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.

CareFirst Behavioral Health Digital Resource

CareFirst is working with 7 Cups, an online emotional support company that uses a robust technology platform that allows you to access a variety of support options through your smartphone, computer or tablet. The four main support options are: trained volunteer listeners, growth paths, community support, and licensed professionals. If needed, you have the opportunity to connect with behavioral health providers in the CareFirst provider network.

CareFirst is working with 7 Cups, an online emotional support company that uses a robust technology platform that allows you to access a variety of support options through your smartphone, computer or tablet. The four main support options are: trained volunteer listeners, growth paths, community support, and licensed professionals. If needed, you have the opportunity to connect with behavioral health providers in the CareFirst provider network.

Ovia Health

Included with your CareFirst WellBeing program for members 18 and over, Ovia offers support for reproductive health, including conceiving, pregnancy, post- partum, parenting, and perimenopause/ menopause. Users will choose their goal and Ovia will customize the member experience to deliver personalized insights, tips and content - which includes access to Care Advocates and coaches specializing in reproductive health.

Follow these steps to get started today!

1. Log in to your CareFirst WellBeing account (or create one at www.carefirst.com/wellbeing)
2. Under Achieve, choose Programs to view your women’s health programs
3. Select Ovia and follow the prompts to get started
4. Download the Ovia app and explore

Included with your CareFirst WellBeing program for members 18 and over, Ovia offers support for reproductive health, including conceiving, pregnancy, post- partum, parenting, and perimenopause/ menopause. Users will choose their goal and Ovia will customize the member experience to deliver personalized insights, tips and content - which includes access to Care Advocates and coaches specializing in reproductive health.

Follow these steps to get started today!

1. Log in to your CareFirst WellBeing account (or create one at www.carefirst.com/wellbeing)
2. Under Achieve, choose Programs to view your women’s health programs
3. Select Ovia and follow the prompts to get started
4. Download the Ovia app and explore

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), routine prenatal and well-child care, child and adult immunizations, tobacco and nicotine cessation programs, obesity/weight loss programs, disease management and wellness programs.  These services are covered at 100% if you use a network provider and the services are described in Section 5, Preventive care. You do not have to meet the deductible before using these services. 

After you have paid the Plan’s deductible, we pay benefits under traditional medical coverage described in Section 5.  The Plan typically pays a higher copay after the deductible for out-of-network care that applies to in-network services.

Covered services include:

• Medical services and supplies provided by physicians and other healthcare professionals
• Surgical and anesthesia services provided by physicians and other healthcare professionals
• Hospital services; other facility or ambulance services
• Emergency services/accidents
• Mental health and substance abuse benefits
• Prescription drug benefits
• Dental benefits

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else’s tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan. In 2024, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $75 per month for a Self Only or $150 per month for a Self Plus One or a Self and Family enrollment.  In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $4,150 for an individual and $8,300 for a family. See maximum contribution information on page 94. You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible.  Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don’t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

• Your contributions to the HSA are tax deductible
• You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.)
• Your HSA earns tax-free interest
• You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS publication 502 for a complete list of eligible expenses)
• Your unused HSA funds and interest accumulate from year to year
• It is portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire

Important consideration if you want to participate in a Healthcare Flexible Spending Account (HCFSA): If you are enrolled in BlueChoice Advantage HDHP with a Health Savings Account (HSA), and start or become covered by a HCFSA healthcare flexible spending account (such as FSAFEDS offers – see Section 11), BlueChoice Advantage HDHP cannot continue to contribute to your HSA.  Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA.  Instead, when you inform us of your coverage in an HCFSA, we will establish an HRA for you.  

If you are not eligible for an HSA, for example, you are enrolled in Medicare or have another health plan; we will administer and provide an HRA instead.  You must notify us that you are ineligible for an HSA as soon as possible.  

In 2024, we will give you an HRA credit of $900 per year for a Self Only enrollment, or $1,800 per year for a Self Plus One enrollment, or $1,800 per year for a Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that do not count toward the deductible. 

HRA features include:

• For BlueChoice Advantage HDHP, the HRA is administered by Further by Health Equity. 
• Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment
• Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by BlueChoice Advantage HDHP
• Unused credits carryover from year to year
• HRA credit does not earn interest
• HRA credit is forfeited if you leave Federal employment or switch health insurance plans
• An HRA does not affect your ability to participate in an FSAFEDS Healthcare Flexible Spending Account (HCFSA).  However, you must meet FSAFEDS eligibility requirements

When you use in-network providers, your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $5,000 for Self Only enrollment and $10,000 for Self Plus One, or Self and Family enrollment, and out-of network care is limited to $7,000 for Self Only enrollment and $14,000 for Self Plus One or Self and Family enrollment.  However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable amount or benefit maximum).  Refer to Section 4, Your catastrophic protection out-of-pocket maximum and BlueChoice Advantage HDHP Section 5 Traditional medical coverage subject to the deductible for more details. 

Out-Of-Pocket Maximum 

• Individual Coverage:
  • The member must meet the individual out-of-pocket maximum.

• Family Coverage:

  • Each member can satisfy their own individual out-of-pocket maximum by meeting the individual out-of-pocket maximum. In addition, eligible expenses of all covered family members can be combined to satisfy the Self and Family out-of-pocket maximum.
  • An individual family member cannot contribute more than the individual out-of-pocket maximum toward meeting the Self and Family out-of-pocket maximum

• Once the family out-of-pocket maximum has been met, this will satisfy the out-of-pocket maximum for all family members. These amounts apply to the out-of-pocket maximum:

  • Co-payments and coinsurance for all covered services
  • Prescription drug benefit Rider co-payments and coinsurance for all covered services
  • Deductible
• Note: When the member has reached the out-of-pocket maximum, no further co-payments, coinsurance or deductible will be required in that benefit period for covered services. The in-network and out-of-network out-of-pocket maximum contributes towards one another. 

BlueChoice Advantage HDHP Section 5(i) describes the health education resources and account management tools available to you to help you manage your healthcare and your healthcare dollars. 

Health Savings Account (HSA)

Health Reimbursement Arrangement (HRA)

Provided when you are ineligible for an HSA

The Plan will establish an HSA for you with our BlueFund Administrator, BlueChoice Advantage HDHP’s fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS.) 

Further by Health Equity is the HRA fiduciary for this Plan.

Set-up fee is paid by the BlueChoice Advantage HDHP.

No per month administrative fee charged by the fiduciary and taken out of the account balance as long as you are enrolled in the plan.

None

You must:

• Enroll in BlueChoice Advantage HDHP
• Have no other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision or long-term care coverage)
• Not be enrolled in Medicare
• Not be claimed as a dependent on someone else’s tax return
• Not have received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits in the last three (3) months
• Enroll in the HSA, as contracted and communicated within 30 days from their effective date
• Exceptions will only be considered if there are special circumstances (ex: for a high-ranking official)

You must enroll in BlueChoice Advantage HDHP.

Eligibility is determined on the first day of the month following your effective day of enrollment and will be prorated for length of enrollment.

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month.  Premium pass through contributions are based on the effective date of your enrollment in the BlueChoice Advantage HDHP.

Note: If your effective date in the HDHP is after the 1^st of the month, the earliest your HSA will be established is the 1^st of the following month. Except for members enrolled during open enrollment with an effective date after the 1st in the month of January.  These members will still receive the January premium contribution.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.).

Eligibility for the annual credit will be determined on the first day of the month and will be prorated for length of enrollment.  The entire amount of your HRA will be available to you upon your enrollment.

For 2024, a monthly premium pass through of $75 will be made by the BlueChoice Advantage HDHP directly into your HSA each month.

For 2024, your HRA annual credit is $900 (prorated for mid-year enrollment).

For 2024, a monthly premium pass through of $150 will be made by the BlueChoice Advantage HDHP directly into your HSA each month

For 2024, your HRA annual credit is $1,800 (prorated for mid-year enrollment).

For 2024, a monthly premium pass through of $150 will be made by the BlueChoice Advantage HDHP directly into your HSA each month.

For 2024, your HRA annual credit is $1,800 (prorated for mid-year enrollment).

The maximum that can be contributed to your HSA is an annual combination of the BlueChoice Advantage HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $4,150 for an individual $8,300 for a family.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS.  To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum allowable contribution.

You are eligible to contribute up to the IRS limit for partial year coverage as long as you maintain your BlueChoice Advantage HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12-month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA.  If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed.  There is an exception for death or disability.

You may rollover funds you have in other HSAs to the BlueChoice Advantage HDHP HSA (rollover funds do not affect your annual maximum contribution under BlueChoice Advantage HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

The full HRA credit will be available, subject to proration, on the effective date of enrollment.  The HRA does not earn interest.

In addition to the pass through contribution, you may make an annual maximum contribution of $3,250.

You cannot contribute to the HRA.

In addition to the pass through contribution, you may make an annual maximum contribution of $6,500.

You cannot contribute to the HRA.

In addition to the pass through contribution, you may make an annual maximum contribution of $6,500.

You cannot contribute to the HRA.

Members may access HSA funds by the following methods:

• Debit card (default option)
• Auto-pay (member may elect this option online)
• Withdrawal form (check or direct deposit)
• Online claims:
• Get reimbursed (payment to member)
• Pay a bill (payment to provider)
• Debit cards are automatically sent to members upon enrollment. Members have the option to elect auto-pay instead of debit card, but members may only choose one of these options.
• Debit cards may be used at the point-of-service for immediate access to available funds.
• Auto-pay claims are processed systematically and do not require manual claims submission. Members pay for out-of-pocket expenses and are then reimbursed for eligible expenses from available funds once the claim is processed.
  Withdrawal forms and online reimbursement options are both available when the member is enrolled in either Debit card or Auto-pay.

Members may access HRA funds by the following methods:

• Debit card (default option)
• Auto-pay (member may elect this option online)
• Withdrawal form (check or direct deposit)
• Online claims:
• Get reimbursed (payment to member)
• Pay a bill (payment to provider)
• Debit cards are automatically sent to members upon enrollment. Members have the option to elect auto-pay instead of debit card, but members may only choose one of these options.
• Debit cards may be used at the point-of-service for immediate access to available funds.
• Auto-pay claims are processed systematically and do not require manual claims submission. Members pay for out-of-pocket expenses and are then reimbursed for eligible expenses from available funds once the claim is processed.
  Withdrawal forms and online reimbursement options are both available when the member is enrolled in either Debit card or Auto-pay.

You can pay the out-of-pocket expenses for yourself, your spouse or your dependents (even if they are not covered by the BlueChoice Advantage HDHP) from the funds available in your HSA.

See IRS Publication 502 for a list of eligible medical expenses.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the BlueChoice Advantage HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.

See Availability of funds below for information on when funds are available in the HRA.

Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable.  Most other types of medical insurance premiums are not reimbursable.

If you are under age 65, distributions/withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions/withdrawal can be used for any reason without being subject to the 20% penalty, however they will be subject to ordinary income tax.

Not applicable – distributions will not be made for anything other than non-reimbursed qualified medical expenses.

Funds are not available for withdrawal until all the following steps are completed:

• Your enrollment in BlueChoice Advantage HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change)
• The BlueChoice Advantage HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish and by contributing the minimum amount required to establish an HSA
• The fiduciary sends you HSA paperwork for you to complete and the fiduciary receives the completed paperwork back from you

The entire amount of your HRA will be available to you upon your enrollment in the BlueChoice Advantage HDHP.

FEHB enrollee

BlueChoice Advantage HDHP

You can take this account with you when you change plans, separate or retire.

If you do not enroll in another HDHP, you can no longer contribute to your HSA.

If you retire and remain in BlueChoice Advantage HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under BlueChoice Advantage HDHP will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited.

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS.  You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit.  If you contribute, you can claim the total amount you contributed for the year as a tax deduction when you file your income taxes.  Your own HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction).  You receive tax advantages in any case.  To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS.  You have until April 15 of the following year to make HSA contributions for the current year.

If you newly enroll in BlueChoice Advantage HDHP during Open Season and your effective data is after January 1^st, or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed.  There is an exception for death or disability.

If you are age 55 or older, the IRS permits you to make additional contributions to your HSA.  The allowable additional contribution is $1,000.  Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the IRS website at www.irs.gov or request a copy of IRS Publication 969 by calling 1-800-829-3676.
www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx.

You can pay for “qualified medical expenses;” as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling (800) 829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Publications”.  Note: although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA.  Also, insurance premiums are reimbursable under limited circumstances.

You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.

You will receive a periodic statement that shows the “premium pass through”, withdrawals, and interest earned on your account.  In addition, you will receive an Explanation of Payment statement when you withdraw money from your HSA.

You can request reimbursement in any amount.  However, funds will not be disbursed until your reimbursement totals at least $25.

If you do not qualify for an HSA when you enroll in BlueChoice Advantage HDHP, or later become ineligible for an HSA, we will establish an HRA for you.  Also, if you do not open an account within 30 days of receiving the HSA application/forms, your funds will be automatically defaulted into an HRA account.  If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you.  You must tell us if you become ineligible to contribute to an HSA.

Please review the chart on page (Applies to printed brochure only) which details the differences between HRA and an HSA. The major differences are: 

• you cannot make contributions to an HRA
• funds are forfeited if you leave the HDHP
• an HRA does not earn interest
• HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the BlueChoice Advantage HDHP.  FEHB law does not permit qualified medical expenses to include services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.

Routine physicals allowed once per benefit period including screenings, such as:

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, 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/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women 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 preventive care benefits for women go to 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 
• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): basedon the Advisory Committee on Immunization Practices (ACIP) schedule.
• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities.

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/Tdap, 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/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

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 either in-network or out-of-network, you are responsible for paying the allowable charges until you meet the deductible. Only CareFirst allowable charges are applicable to the deductible. 

100% of allowable charges until you meet the deductible of  $1,600 per Self Only enrollment, $3,200 per Self Plus One enrollment and Self and Family enrollment for in-network services and $3,200 per Self Only, and $6,400 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

CloseKnit, provides virtual only primary care services through a dedicated care team of physicians, nurse practitioners, physician assistants, licensed professional counselors and licensed clinical social workers

• Well care / Annual Wellness
• Preventative care
• Urgent Care
• Lifestyle support
• Chronic condition prevention and management
• Medication management
• Clinical educational support
• Behavioral Health and mental health support through professional counselors
• Care Coordination, including ongoing assistance with care activities such as arranging appointments with specialists, refiling prescriptions, etc.

In-network:

deductible, then no copay

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 and Postpartum care
• Screening for gestational diabetes 
• Delivery
• Screening and counseling for prenatal and postpartum depression

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. 

Note: Breast pumps are available pre or post-natal.

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 (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.

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.

Note: Members enrolled in the High-Risk OB Care Management Program may be eligible to receive a home blood pressure cuff.

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:

• $0 copay

Out-of-network:

• $80 copay
  
  

Not covered:

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

FDA Approved Fertility Apps

In-network:

• No copay

Out-of-network:

• No copay

Diagnosis and treatment of infertility specific to:

• Artificial insemination:
  • Intravaginal Insemination (IVI)
  • Intracervical Insemination (ICI)
  • Intrauterine Insemination (IUI)
• Fertility drugs (See Section 5f)

Note:

• We cover drugs for the treatment of infertility, when deemed medically necessary. 
• When covered for artificial insemination, injectable drugs are medical benefits, and oral drugs are benefits under prescription drug coverage. See Section 5(f).
• Prior authorization for the treatment must be obtained from CareFirst BlueChoice.
• Benefits are limited to three (3) attempts per benefit period. 
• 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 General Exclusions in Section 6 and the Not Covered section at the end of this Description of 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.
• Infertility is the inability to conceive or produce conception after 1 year of unprotected sex when an individual is under 35 years of age, or 6 months for an individual age 35 or older or failed attempts at artificial insemination. There are various reproductive treatments available for people facing infertility, which are customized according to their medical history and diagnostic results.

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 three (3) attempts per live birth. If a live birth occurs within the 3 attempts the benefit renews. If the member has 3 failed attempts, the benefit is exhausted for the lifetime of the coverage even if the member switches plans the exhausted benefit does not renew.

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) medical procedures. See Section 5(f) for In vitro fertilization (IVF) drugs

• 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

• 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 office 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: