We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Coverage under this plan qualifies as minimum essential coverage. 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.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

See https://health-benefits.opm.gov/PSHB/ or enrollment information as well as:

• Information on the PSHB Program and plans available to you
• A health plan comparison tool

Note: Contact the USPS for information on how to enroll in a PSHB Program Plan through the PSHB System.

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 PSHB 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. You will be responsible for making changes to your enrollment status through the PSHB System.  In some cases, your employing or retirement office may need to submit documentation. For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your PSHB 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. 

You enroll in a PSHB Program Plan and make enrollment changes in the PSHB System located at https://health-benefits.opm.gov/PSHB/ For assistance with the PSHB System, call the PSHBP Helpline at (844) 451-1261. 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 request. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s PSHB enrollment.

Use the PSHB System if you want to change from Self Only to Self Plus One or Self and Family, and to add or remove a family member. 

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits.  Please, report changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26 through the PSHB System. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26^th 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 PSHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another PSHB or 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 PSHB Program, change your enrollment, or cancel coverage using the PSHB System.  For a complete list of QLEs, visit the PSHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from 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.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother’s maternity stay.

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 PSHB 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 PSHB 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 child identified in the order who is still eligible under the PSHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.   

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for PSHB coverage, you must continue your PSHB 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.

For annuitants who are required to be enrolled in Medicare Part B as a condition to continue PSHB coverage in retirement: If you enroll in Medicare Part B and continue PSHB coverage in retirement, the child equity law applies to you and you cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your child(ren) live as long as the court/administrative order is in effect. You cannot be compelled to enroll or remain enrolled in Medicare Part B to maintain your PSHB enrollment as a condition to satisfy a court/administrative order. However, if you do not enroll (or remain enrolled) in Medicare Part B as required to continue your PSHB coverage in retirement (notwithstanding an existing court/administrative order), you will not be able to continue your PSHB coverage in retirement.

Our PDP EGWP is only available to Postal Service annuitants who are Medicare Part D-eligible and their covered Medicare Part D-eligible family members. Our PDP EGWP is not an open market Medicare Part D Plan.  If you are an active Postal Service employee, or covered family member, and become eligible to enroll in Medicare Part D, you are not eligible to enroll in our PDP EGWP.  Please, contact CMS for assistance (800) 633-4227. 

The benefits in this brochure are effective January 1.  If you joined this Plan during Open Season, your coverage and premiums begin on January 1. If you joined at any other time during the year, your employing or retirement 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 are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the PSHB Program.  Generally, you must have been enrolled in the FEHB and/or PSHB Program for the last five 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.

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.

If you are eligible for coverage under spouse equity, you are only eligible to enroll in the FEHB Program. If you are not eligible for coverage under spouse equity and you are otherwise eligible for Temporary Continuation of Coverage (TCC), then you could enroll in TCC under the PSHB Program.

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 enter the date of the divorce or annulment and remove your ex-spouse in the PSHB System. We may ask for a copy of the divorce decree as proof. If you need to change your enrollment type, you must use the PSHB System. 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 coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). Former spouses eligible for coverage under the spouse equity law are not eligible to enroll in the PSHB Program. However, former spouses eligible for coverage under the spouse equity law may enroll in the FEHB Program. (Former Spouses seeking but not yet adjudicated as eligible for Spouse Equity may be entitled to TCC under a PSHB plan in the interim).

When a Postal Service annuitant who is Medicare Part D-eligible or their covered Medicare-eligible family member opts out of or disenrolls from our PDP EGWP, they will not have our prescription drug coverage under this plan. If you do not maintain creditable coverage, re-enrollment in our PDP EGWP may be subject to a late enrollment penalty. Contact us for additional information at (833) 489-1316.

If you leave Federal service, 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 PSHB enrollment after you retire, if you lose your Federal job, or if you are a covered child and you turn 26.

You may not elect TCC if you are fired from your Federal 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 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 PSHB Program coverage.

You may convert to a non-PSHB 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 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 PSHB 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 833-489-1316 or visit our website at www.carefirst.com/pshbp

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 Health and 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 PSHB System enrollment confirmation.  

Note:  If you are enrolled in our Medicare Part D PDP EGWP, you will receive a second ID card for your prescription drug benefits.

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 at (833)-489-1316 or write to us at Mail Administrator, P.O. Box 14114, Lexington, KY 40512-4114. You may also request replacement cards through our website: www.carefirst.com/pshbp

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 option. 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 (833)-489-1316 of your selection.

PSHB Carriers must have clauses in their in-network (participating) provider 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.

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 (833)-489-1316 or www.carefirst.com/pshbp 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.

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/pshbp.

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 your coverage changed from the FEHB to the PSHB and your health plan does not participate in the PSHB; or
  • lose access to your specialist because we drop out of the Postal Service Employees Health Benefits (PSHB) Program and you enroll in another PSHB program plan; or:
  • lose access to your specialist because we terminate our contract with your specialist for other than cause; or
  • lose access to your specialist because we reduce our service area and you enroll in another PSHB plan; you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. 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 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 (833)-489-1316. If you are new to the PSHB 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 this PSHB plan, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center; 
• 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 PSHB 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)
• Inpatient and outpatient hospital Repetitive Transcranial Magnetic Stimulation (TMS)
• Inpatient Behavioral Health and Substance Use Disorder
• Residential Treatment Centers (RTC)
• See www.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 Plan:
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 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.

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 layperson 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 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 (833)-489-1316. You may also call OPM’s Postal Service Insurance Operations (PSIO) at (202) 936-0002 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous 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 (833)-489-1316. 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 telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

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.

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.

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

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 healthcare 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 more days.
3. 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.

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 telephone, 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.

Note: If you are enrolled in our Medicare PDP EGWP and do not agree with our benefit coverage decision you have the right to appeal.  See Section. 8(a) for information about the PDP EGWP appeal process.

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

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 Blue Value Plus option, you pay a copayment of $15 per office visit, and when you go to an outpatient hospital for surgery, you pay a facility copayment of $200.

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

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.

The BlueChoice Advantage HDHP has a deductible of $1,650 for Self Only enrollment or $3,300 for Self Plus One and Self and Family enrollment for in-network services and $3,300 for Self Only enrollment and $6,600 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.

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).

Note: If you change plans during Open Season, the effective date of your new PSHB plan is January 1 of the next year, and a new deductible starts on January 1. If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance is the percentage of our allowance 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 allowance for durable medical equipment

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 BlueChoice Advantage HDHP option, 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 in Section 5(a) for detail for when network providers may bill for balances.

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 Blue Value Plus, once your expenses for in-network care (coinsurance, co-payments and deductible) total $6,500 for Self Only enrollment or $13,000 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 $5,500 for Self Only enrollment or $11,000 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 $7,500 for Self Only enrollment and $15,000 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 HDHP BlueChoice Advantage option.
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.

For members enrolled in our Plan's associated PDP EGWP, we are required to accumulate all members’ actual out-of-pocket costs for Medicare-covered drugs, services and supplies toward the PSHB catastrophic maximum(s).

If you are enrolled in our Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP), the prescription drug out-of-pocket maximum is $2,000.  After this maximum is met, we pay 100% of all eligible covered prescription drug benefits.

If you changed to this PSHB Plan during Open Season from a plan with a catastrophic protection benefit the effective date of the change is January 1, and covered expenses that apply to this plan’s catastrophic protection benefit starts on January 1. 

Note: If you change PSHB plans during Open Season the effective date of your new PSHB plan is January 1 of the next year, and a new catastrophic protection accumulation starts on January 1. If you change plans at another time during the year, you must begin a new catastrophic protection accumulation under your new plan.

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

Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member.  They may not seek more than their governing laws allow.  You may be responsible to pay for certain services and charges.  Contact the government facility directly for more information. 

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/pshbp or contact the health plan at (833) 489-1316.

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 - $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:

• $15 copay

Telemedicine Services:

Telemedicine refers to the use of a combination of interactive audio, video, or other electronic media used by a licensed health care provider for the purpose of diagnosis, consultation, or treatment consistent with the provider's scope of practice.

Note: Telemedicine must have a video and audio component. Telephone consultations are not a covered service.

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

Example:

- If services are rendered by a PCP, the member would be responsible for the PCP cost- share.
-If services are rendered by a Specialist, the member would be responsible for the Specialist cost-share.

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

Tests, such as:

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

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:
$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:

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer.  For a complete list of screenings go to the website at 
  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.hrsa.gov/womens-guidelines
• 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

• Routine mammogram 

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. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at 
  www.cdc.gov/vaccines/schedules/

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

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

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

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

• Intensive nutrition and behavioral weight-loss counseling therapy,

• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Note: 

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) or 5(f)(a) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See section 5(b) for Surgery requirements and cost share.
• Also see Section 5(h) for additional programs that offer nutritional and physical activity support.

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 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
www.brightfutures.aap.org

Children’s immunization’s endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the website at https://www.cdc.gov/vaccines/schedules/index.html

In-network:

• No copay

You can also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at
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

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Note:

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See section 5(b) for Surgery requirements and cost share.
• Also see Section 5(h) for additional programs that offer nutritional and physical activity support.

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- $50
• Professional Services at Delivery - 25% of plan allowance

Breastfeeding and lactation support, supplies and counseling for each birth.

Note:

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

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.

Breast pumps are available one per calendar year pre- or post-natal.

Here are some things to keep in mind:

• You do not need to pre-certify your vaginal delivery; see page (Applies to printed brochure only)for other circumstances, such as extended stays for you or your baby.
• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period
• 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. 
• 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 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. In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

In-network:

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

Not covered:

• Doulas
• Surrogacy

All charges

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes:  

• Voluntary female sterilization 
• 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: See additional Family Planning and Prescription drug coverage Section 5(f) or 5(f)(a).

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

Your provider can request authorization by following the steps outlined at 
www.provider.carefirst.com/providers/medical/in-network-precertification-preauthorization.page. Urgent requests will be reviewed within 24 hours. 

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

In-network:

• No copay 

Voluntary male sterilization 

Hospital services are covered under Sect. 5(c)

Surgical benefits are covered under Sect. 5(b)

In-network:

• No copay

FDA Approved Fertility Apps

In-network:

• No copay

Not covered:

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

All charges

Diagnosis and treatment of infertility specific to:

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

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 PSHB 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

In vitro fertilization (IVF)

IVF involves stimulation of the ovaries with exogenous hormones, retrieval of oocytes/ova (eggs), fertilization of the oocytes in a petri dish, and the transfer of any resulting embryo(s) back into the uterus.

Note:

• Benefits are limited to three attempts per live birth and limited to $45,000 payment per plan year 

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

• IVF benefits are considered if the patient has been unable to attain a successful pregnancy through a less costly infertility treatment under the policy

• 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.
• See Section 5(f) or 5(f)(a) for In vitro fertilization (IVF) drugs
• Procedure is covered regardless of whether the couple has a relationship under which the PSHB Program recognizes each partner as a spouse of the other.

• The in vitro fertilization procedures must be performed at medical facility that conforms to the American College of Obstetricians and Gynecologists (ACOG) guidelines for in vitro fertilization clinics or to the American Society for Reproductive Medicine (ASRM), (formerly the American Fertility Society) minimal standards for programs of in vitro fertilization.
• A completed Assisted Reproductive Technology Pre-Treatment Form is required to be submitted for approval, by the Physician.  This form may be obtained on the CareFirst website at 
  www.carefirst.com/providers.
• Once services are approved, providers will need to obtain separate authorization for infertility medication.

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

• Fertility drugs see Section 5(f) or 5(f)(a)

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

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

Not covered: 

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

All charges

• Testing and treatment
• Allergy injections

In-network:

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

Allergy serum

In-network:

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

Not covered:

Provocative food testing and Sublingual allergy desensitization

All charges

• 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.

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. See Other services under You need prior Plan approval for certain services on page (Applies to printed brochure only)

For Chemotherapy and Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy see Infusion Services under Section 5 (a)

For services rendered by Home Health provider see Home Health benefits

In-network:

• PCP - $15 copay
• Specialist - $50 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 - $20 copay
• Outpatient Hospital - $200 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:

• $50 office copay

Not covered:

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

All charges

• 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:

• $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:

• $50 office copay

Not covered

Benefits are not provided for maintenance cardiac rehabilitation

All charges

Pulmonary Rehabilitation

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

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

In-network:

• $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, children.

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 the plan allowance

Limited to $2,000 payment per 36 months

Not covered:

Hearing services that are not shown as covered

All charges

• 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:

• $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

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

All charges

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:

• 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.

All charges

• 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

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)

All charges

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

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:

• 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

All charges

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:

• $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.

All charges

Acupuncture-by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner

Limited to 20 visits per Benefit Period.

In-Network:

• $50 office copay

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback

All charges

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. 
• Medically necessary nutrition therapy
• Medically necessary professional nutritional counseling

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

All charges

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 - $50 copay
• Freestanding - $50 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
• Treatment of burns

Note: For female surgical family planning procedures see Family Planning Section 5(a)

Note: For male surgical family planning procedures see Family Planning Section 5(a)

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 – $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)

All charges

• 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 – $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 – $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

All charges

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 – $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

All charges

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 – $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

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

Mini-transplants performed in a clinical trial setting (non-myeloablative, 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
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • 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 – $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 are 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 demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia
• Mini-transplants (non-myeloablative allogeneic, 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 lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
    Multiple sclerosis
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MDDs)
  • 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 lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • 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 – $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

All charges

Professional services provided in –

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

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:
• 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:
• 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

• 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): $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:

• Labs: $50 copay
• X-Rays: $100 copay
• Other diagnostic services: $100 copay

Specialty Imaging:

• MRA/MRS
• MRI
• PET
• CAT scans

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- 25% of plan allowance

   Not covered:

• Custodial care

All charges

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:

• No Charge

Not covered: Independent nursing, homemaker services

All charges

• 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:

• $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 - $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

Not covered: Elective care or non-emergency care

All charges

• 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:
$200 copay per transport

Not covered: Air ambulance, unless medically necessary and no other transport is reasonably available.

All charges

• 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 - 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:

• 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:

Facility: $50 copay

Not covered:

• 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

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

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

Opioid Reversal Agents- No deductible, then $0 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

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/pshb for any updates to this list and for additional information on how these items are covered.

No copay

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories 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. 

Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.

• 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. A response will be provided within 24hrs of receiving the completed Exception Request Form. 

• If you have difficulty accessing contraceptive coverage or other reproductive healthcare you can contact contraception@opm.gov.

• Reimbursement for over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits see Section 5(a)

No copay

Not covered

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

All charges

The following are covered:

Preventive Medications with USPSTF A and B recommendations. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to
www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

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.

Nothing: when prescribed by a healthcare professional and filled by a network pharmacy.

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.

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a plan pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to
www.findtreatment.samhsa.gov/.

No deductible, then $0 copay

Not covered:

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

All charges

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 
• Specialty drugs are limited to a 34-day supply for the first initial fill

Your plan offers coverage for prescription drugs on a Medicare formulary (drug list). This is considered your Primary / Medicare Prescription Drug Coverage. If your drug is not covered on the Medicare formulary, your plan offers secondary coverage as well. Your plan includes additional coverage of some prescription drugs (enhanced drug coverage) not normally covered in a Medicare prescription drug plan.

Search this plan’s Medicare Part D formulary. If your prescription drug is not covered on the Medicare formulary, you will need to check the CareFirst Prescription Formulary 4 for your drug. The formulary files can be found at www.carefirst.com/pshbp. If the drug is covered under both formularies your will pay the lesser of the applicable cost share listed below. 

Medicare Part D Prescription Drug Benefits:

Retail: up to 30-day supply per copay:

• Tier 1: Preferred Generic: $10 copay
• Tier 2: Generic: $10 copay
• Tier 3: Preferred Brand: $50 copay
• Tier 4: Non-Preferred Drug: deductible then, $100 copay
• Tier 5: Specialty Tier: deductible then, $150 copay

Maintenance Drugs Up to 90-day supply per copayment:

• Tier 1: Preferred Generic: $20 copay
• Tier 2: Generic: $20 copay
• Tier 3: Preferred Brand: $100 copay
• Tier 4: Non-Preferred Drug: deductible then, $200 copay
• Tier 5: Specialty Tier: Not Covered

Note: Under the Medicare Part D Prescription Drug Benefits if a prescriber writes "Dispense as Written" for the brand name drug, and the member receives a brand name drug when a Federally approved generic drug is available, the member will pay the brand copay.

Secondary Coverage: Blue Value Plus Formulary 4 Prescription Benefits

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

Opioid Reversal Agents- No deductible, then $0 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

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories 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. A response will be provided within 24hrs of receiving the completed Exception Request Form. 

• If you have difficulty accessing contraceptive coverage or other reproductive healthcare you can contact contraception@opm.gov.

• Reimbursement for over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits see Section 5(a)

$0 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 websitewww.carefirst.com/pshbp for any updates to this list and for additional information on how these items are covered.

Nothing: when prescribed by a healthcare professional and filled by a network pharmacy.

Not covered

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

All charges

The following are covered:

• Preventive Medications with a USPSTF A and B recommendations. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to
  www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Nothing: when prescribed by a healthcare professional and filled by a network pharmacy.

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.

Nothing: when prescribed by a healthcare professional and filled by a network pharmacy.

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

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a plan pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to
www.findtreatment.samhsa.gov/

$0 copay

Not covered:

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

All charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

In-network:

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

We have no other dental benefits

Not covered

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 of 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).

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.

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

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

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.

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

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.

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.

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.

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. 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. Members who choose the high-deductible health plan option, and choose to fund their account, are not allowed to use their card funds for eligible medical and/or prescription expenses until first satisfying their IRS minimum deductible. However, these members can use the card funds for eligible dental and or vision expenses that are part of the benefit plan.

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 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

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses 

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 2025, 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 $4,300 for an individual and $8,550 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, 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 2025, 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 a Healthcare Flexible Spending Account (HCFSA).  However, you must meet HCFSA 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 $5,500 for Self Only enrollment and $11,000 for Self Plus One, or Self and Family enrollment, and out-of network care is limited to $7,500 for Self Only enrollment and $15,000 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. If you are enrolled in our PDP EGWP, see page (Applies to printed brochure only) for additional information about your out-of-pocket maximum.

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.

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.

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 2025, a monthly premium pass through of $75 will be made by the BlueChoice Advantage HDHP directly into your HSA each month.

For 2025, your HRA annual credit is $900 (prorated for mid-year enrollment).

For 2025, a monthly premium pass through of $150 will be made by the BlueChoice Advantage HDHP directly into your HSA each month

For 2025, your HRA annual credit is $1,800 (prorated for mid-year enrollment).

For 2025, a monthly premium pass through of $150 will be made by the BlueChoice Advantage HDHP directly into your HSA each month.

For 2025, 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 $4,300 for an individual $8,550 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 $3,400.

You cannot contribute to the HRA.

In addition to the pass through contribution, you may make an annual maximum contribution of $6,750.

You cannot contribute to the HRA.

In addition to the pass through contribution, you may make an annual maximum contribution of $6,750.

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.

See IRS Publications 502 and 969 for information on eligible medical expenses. 

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.

PSHB 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.

Yes, accumulates without a maximum cap.

Yes, accumulates without a maximum cap.

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 an HDHP during Open Season your effective date is January 1^st, or if you enroll at any other time and 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.ustreas.gov/offices/public-affairs/hsa/

If you have not named beneficiary and you are married, your HSA becomes your spouse’s; otherwise, your HSA becomes part of your taxable estate.

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, 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 detailed information of IRS-allowable expenses, request a copy of IRS Publication 502 and 969 by calling 1-800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Publications.” Note: Although 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 don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you. 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 an 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 HDHP. PSHB 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. The following preventive services are covered at the time interval recommended at each of the links below:

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer.  For a complete list of screenings go to the website at 
  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.hrsa.gov/womens-guidelines
• 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:

• Calendar year deductible applies
• No Copay

• Routine mammogram 
• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at 
  www.cdc.gov/vaccines/schedules/

In-network:

• No copay

Out-of-network:

• No 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 

Obesity counseling, screening, and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Note:

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) or 5(f)(a) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.
• Also see Section 5(h) for additional programs that offer nutritional and physical activity support.

In-network:

• No copay

Out-of-network:

• Calendar year deductible applies
• 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 as described in the Bright Future Guidelines provided by the American Academy of Pediatrics

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 listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Note: You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at: 
www.uspreventiveservicestaskforce.org

HHS:  www.healthcare.gov/preventive-care-benefits/

ACIP recommendations on immunizations, please refer to the National Immunization Program Web site at: www.cdc.gov/vaccines/schedules/index.html 

CDC:  www.cdc.gov/vaccines/schedules/index.html  

For additional  information:

www.healthfinder.gov/myhealthfinder/default.aspx

Note: For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to www.brightfutures.aap.org/Pages/default.aspx

In-network:

• No copay

Out-of-network:

• Calendar year deductible applies
• No copay

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy 

• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Note

When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.

When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

In-network:

• No copay

Out-of-network:

• Calendar year deductible applies
• No 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 2 treatments per calendar year
• Fluoride applications (limited to 1 treatment per calendar year and for children under age 16)
• Sealants – (once every 3 years, from the last date of service, on permanent molars for children under age 16)
• Space maintainer (primary teeth only)
• Bitewing X-ray s (one set per calendar year)
• Complete series X-rays (one complete series every 3 years)
• Periapical X-rays
• Routine oral evaluations (limited to 2 per calendar year)

All charges

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 $1,650 per Self Only enrollment, $3,300 per Self Plus One enrollment and Self and Family enrollment for in-network services and $3,300 per Self Only, and $6,600 per Self Plus One and Self and Family for out-of-network care.

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

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

Professional services of physicians:

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

Office/Outpatient Hospital

In-network:

• PCP - No copay
• Specialist - $35 copay

Out-of-network: 

• $80 copay

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

Inpatient Hospital/Skilled Nursing

In-network:

• Deductible, then 20% of plan allowance

 Out-of-network:

• Deductible, then 30% of plan allowance 

Convenience care (Retail health clinic):

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

In-network: Deductible, then $0 copay

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

Telemedicine Services:

Telemedicine refers to the use of a combination of interactive audio, video, or other electronic media used by a licensed health care provider for the purpose of diagnosis, consultation, or treatment consistent with the provider's scope of practice.

Note: Telemedicine must have a video and audio component. Telephone consultations are not a covered service.

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

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 and lactation support, supplies and counseling for each birth

Note: Breast pumps are available one per calendar year 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 pre-certify your vaginal delivery; see page (Applies to printed brochure only) for other circumstances, such as extended stays for you or your baby.
• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period.
• 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. 
• 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 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. In addition, circumcision is covered at the same rate as for regular medical or surgical 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
• Surrogacy

All Charges

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes:  

• Voluntary female sterilization 
• 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: See additional Family Planning and Prescription drug coverage 5(f) or 5(f)(a).

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

Your provider can request authorization by following the steps outlined at 
www.provider.carefirst.com/providers/medical/in-network-precertification-preauthorization.page Urgent requests will be reviewed within 24 hours. 

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

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

All charges

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 5(f) or 5(f)(a)

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 PSHB 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

In vitro fertilization (IVF)

IVF involves stimulation of the ovaries with exogenous hormones, retrieval of oocytes/ova (eggs), fertilization of the oocytes in a petri dish, and the transfer of any resulting embryo(s) back into the uterus.

Note:

• Benefits are limited to three attempts per live birth and limited to $45,000 payment per plan year 

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

• IVF benefits are considered if the patient has been unable to attain a successful pregnancy through a less costly infertility treatment under the policy

• 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.
• See Section 5(f) or 5(f)(a) for In vitro fertilization (IVF) drugs
• Procedure is covered regardless of whether the couple has a relationship under which the PSHB Program recognizes each partner as a spouse of the other.

• The in vitro fertilization procedures must be performed at medical facility that conforms to the American College of Obstetricians and Gynecologists (ACOG) guidelines for in vitro fertilization clinics or to the American Society for Reproductive Medicine (ASRM), (formerly the American Fertility Society) minimal standards for programs of in vitro fertilization.
• A completed Assisted Reproductive Technology Pre-Treatment Form is required to be submitted for approval, by the Physician.  This form may be obtained on the CareFirst website at www.carefirst.com/providers.
• Once services are approved, providers will need to obtain separate authorization for infertility medication.

In-network:

• deductible then, 50% coinsurance

Out-of-network:

• deductible then, 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

• Fertility drugs see Section 5(f) or 5(f)(a)

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:

• 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

All charges

• 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.

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 - Deductible, then $20 copay
OP Hospital (attended) - Deductible, then $200 copay

Out-of-network:
Home/Office/Freestanding - Deductible, then $80 copay
OP Hospital - Deductible, then $500 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: Occupational Therapy is limited to the use of purposeful activity or interventions designed to achieve functional outcomes that promote health, prevent injury or disability, and that develop, improve, sustain or restore the highest possible level of independence of an individual.

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

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

In-network:

• $35 office copay

Out-of-network:

• $80 office copay

Not covered:

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

All charges

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

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

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

In-network:

• $35 office copay

Out-of-network:

• $80 office copay

Not Covered:

• Benefits are not provided for maintenance cardiac rehabilitation.

All charges

Pulmonary Rehabilitation

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

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

In-network:

• $35 office copay

Out-of-network:

• $80 office copay

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

In-network:

• Deductible, then $35 office copay

Out-of-network:

• Deductible, then $80 office copay

Not covered:

• Benefits delivered through early intervention or school services

All charges

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

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

In-network:

• $35 per visit

Out-of-network:

• $80 copay

• Hearing Aids

  • Medically necessary external hearing aid is covered up to our plan allowance every 36 months.

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

In-network:

• 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 plan allowance. Participating providers will advise you in writing in advance if you will have a balance.

Not covered:

• Hearing services that are not shown as covered

All charges

Medical Vision Services

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

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

In-network:

• Specialist-$35 copay

Out-of-network:

• $80 copay

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

In-network:

• $10 per visit at Davis Vision Providers

Out-of-network:

• All charges above $33

• Not covered:

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

All charges

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

In-network:

• $35 copay

Out-of-network:

• $80 copay

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

Not covered:

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

All charges

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

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

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

In-network:

• Deductible, then 25% of plan allowance

Out-of-network:

• Deductible, then 25% of plan allowance

Not covered:

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

All charges

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

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

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

In-network:

• Deductible, then 25% of plan allowance

Diabetic Supplies- no deductible, 25% of plan allowance up to $100 for a 30-day supply

 Out-of-network:

• Deductible, then 25% of plan allowance

Diabetic Supplies- no deductible, 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 prosthetic devices) 
• 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 Services-Postpartum visits are limited to two (2) per plan year.
• Home Health Services-Post Mastectomy/Testicle Removal visits are limited to four (4) per plan year.

In-network:

• $35 copay

Out-of-network:

• $80 copay

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

All charges

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

In-network:

• $35 copay

Out-of-network:

• $80 copay

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

Not covered:

• Services other than for musculoskeletal conditions of the spine.

All charges

Acupuncture-by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner

Limited to 20 visits per Benefit Period.

In-network:

•  $35 copay

Out-of-network:

• $80 copay

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

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback
• Acupuncture except as listed above

All charges

Coverage is provided for:

• Tobacco and nicotine cessation programs, including individual/group/phone counseling, and for over the counter (OTC) and prescription drugs approved by the FDA to quit smoking (vaping) or other nicotine use. 

In-network:

• No deductible applies
• Nothing for counseling for up to two (2) quit attempts per year.
• Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

Out-of-network:

• $80 copay

• Diabetes self-management
• Medically necessary nutrition therapy
• Medically necessary professional nutritional counseling

In-network:

• No deductible applies
• No copay

Out-of-network:

• $80 copay

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 - Deductible, then No Charge
Office/Freestanding - Deductible, then $35 copay
Outpatient Hospital - Deductible, then $200 copay

Out-of-network:
Home - Deductible, then $50 copay
Office/Freestanding - Deductible, then $80 copay
Outpatient Hospital - Deductible, then $500 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)
• Insertion of internal prosthetic devices.  See 5(a) Orthopedic and prosthetic devices for device coverage information
• Treatment of burns

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

Note: For female surgical family planning procedures see Family Planning Section 5(a)

Note: For male surgical family planning procedures see Family Planning Section 5(a)

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.

In-network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• PCP – No copay
• Specialist – $35 copay

Inpatient Hospital:

• Deductible, then 20% of plan allowance

Out-of-Network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

•  $80 copay

Inpatient Hospital:

• Deductible, then 30% of plan allowance

Not covered:

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

All charges

• 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; birthmarks; and webbed fingers and 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. 

In-network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• PCP – No copay
• Specialist – $35 copay

Inpatient Hospital:

• Deductible, then 20% of plan allowance

Out-of-Network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital

•  $80 copay

Inpatient Hospital:

• Deductible, then 30% of plan allowance

Gender Affirming Care Services

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

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

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

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

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

In-network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• PCP – No copay
• Specialist – $35 copay

Inpatient Hospital:

• Deductible, then 20% of plan allowance

Out-of-Network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital

•  $80 copay

Inpatient Hospital:

• Deductible, then 30% 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

All charges

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.

In-network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• PCP – No copay
• Specialist – $35 copay

Inpatient Hospital:

• Deductible, then 20% of plan allowance

Out-of-Network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital

• $80 copay

Inpatient Hospital:

• Deductible, then 30% 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)

All charges

These solid organ transplants are covered. Solid organ transplants are limited to:

• 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 transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• 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 procedures.

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

In-network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• PCP – No copay
• Specialist – $35 copay

Inpatient Hospital:

• Deductible, then 20% of plan allowance

Out-of-Network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• Deductible, then 30% of plan allowance

Blood or marrow stem cell transplants limited to the stages of the following diagnoses. For the diagnoses listed below, the medical necessity limitation is considered satisfied if the patient meets the staging description.

• Allogeneic transplants for
• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Acute myeloid leukemia
• Advanced Hodgkin’s lymphoma with reoccurrence (relapsed)
• Advanced Myeloproliferative Disorders (MPDs)
• Advanced neuroblastoma
• Advanced non-Hodgkin’s lymphoma with reoccurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic
• Hemoglobinopathy
• lymphoma (CLL/SLL)
• 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, Sanfillippo’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
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with reoccurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with reoccurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Multiple myeloma
  • Medulloblastoma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors

In-network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• PCP – No copay
• Specialist – $35 copay

Inpatient Hospital:

• Deductible, then 20% of plan allowance

Out-of-Network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital

•  $80 copay

Inpatient Hospital:

• Deductible, then 30% of plan allowance

Mini-transplants performed in a clinical trial setting (non-myeloablative, 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 reoccurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with reoccurrence (relapsed)
  • Acute myeloid leukemia 
  • Advanced Myeloproliferative Disorders (MPDs)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal nocturnal hemoglobinuria
    (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 reoccurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with reoccurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Epithelial ovarian cancer
  • Neuroblastoma

In-network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• PCP – No copay
• Specialist – $35 copay

Inpatient Hospital:

• Deductible, then 20% of plan allowance

Out-of-Network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

•  $80 copay

Inpatient Hospital:

• Deductible, then 30% of plan allowance

These blood or marrow stem cell transplants are 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
  • Aggressive non-Hodgkin lymphomas
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle cell anemia
• Mini-transplants (non-myeloablative allogeneic, 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 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
  • Breast Cancer
  • Childhood  rhabdomyosarcoma
  • Chronic myelogenous leukemia
  • Chronic lymphocytic lymphoma/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

In-network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• PCP – No copay
• Specialist – $35 copay

Inpatient Hospital:

• Deductible, then 20% of plan allowance

Out-of-Network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• Deductible, then 30% of plan allowance

National Transplant Program (NTP)

• Note: We cover related medical and hospital expenses of the donor when we cover the recipient.  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.

In-network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital:

• PCP – No copay
• Specialist – $35 copay

Inpatient Hospital:

• Deductible, then 20% of plan allowance

Out-of-Network

Office/Ambulatory Surgical Center (ASC)/Outpatient Hospital

•  $80 copay

Inpatient Hospital:

• Deductible, then 30% 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

All charges

Professional services provided in –

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

In-network

Office:

• PCP – No copay
• Specialist – $35 copay

Ambulatory Surgical Center (ASC):

• PCP – No copay
• Specialist – $35 copay

Outpatient Hospital:

• PCP – No copay
• Specialist – $35 copay

Inpatient Hospital:

• Deductible, then 20% of plan allowance

Out-of-Network

Office:

• $80 copay

Ambulatory Surgical Center (ASC):

• $80 copay

Outpatient Hospital:

• $80 copay

Inpatient Hospital:

• Deductible, 30% 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:

• Deductible, then 20% of plan allowance

Out-of-network:

• Deductible, then 30% of plan allowance

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• 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
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

Note: Hospitalization solely for Acute Rehabilitation is limited to 90 days per benefit period. 

In-network:

• Deductible, then 20% of plan allowance

Out-of-network:

• Deductible, then 30% 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

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

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:

• Calendar year deductible applies
• $100 copay at an ambulatory surgical center
• $300 copay in the outpatient department of a hospital for surgical procedures
• $200 for non-surgical hospital outpatient and clinic visit 

Out-of-network:

• Calendar year deductible applies
• $500 copay at an ambulatory surgical center
• $500 copay in the outpatient department of a hospital and clinic visit

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

• Non-surgical
• Includes but, not limited to EKG's and EEG's
• Specialty Imaging

In-Network:

1) Labs: Deductible then, $35

2) X-Rays: Deductible then, $50

3) Other diagnostic services: Deductible then, $50

4) Specialty Imaging: Deductible then, $100

Out-of-Network:

• Deductible, then 30% of plan allowance 

Not covered: Blood and blood derivatives not replaced by the member

All charges

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 cover 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

Not covered:  Custodial care

All charges

If terminally ill, you are covered for a 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.

Note:  Hospice services must be pre-approved

In-network:

• Deductible applies
• $35 copay

Out-of-network

• Deductible applies
• $80 copay

Not covered: Independent nursing, homemaker services

All charges

• Local 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.

In-network:

• Calendar year deductible applies
• $100 per trip

Out-of-network:

• Calendar year deductible applies
• $150 per trip
• Non-participating provider may charge you for the amount in excess of our allowed benefit.

Not covered:  Air Ambulance unless medically necessary and no other transport is reasonably available.

All Charges

• 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 non-participating provider, the member is not responsible for amounts in excess of the allowed benefits. 

In-network:

• Emergency Room - $300 copay per visit (waived if admitted)
• Emergency Room-Professional Services - No copay
• Urgent care center - $50 copay per visit

Out-of-network:

• Emergency Room - $300 copay per visit (waived if admitted)
• Emergency Room-Professional Services - No copay
• Urgent care center - $50 copay per visit

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

Not covered: Elective care or non-emergency care

All charges

• 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:

• Calendar year deductible applies
• $100 per trip

Out-of-network:

• Calendar year deductible applies
• $150 per trip
• Non-participating provider may charge you for the amount in excess of our allowed benefit.

Not covered: Air Ambulance unless medically necessary and no other transport is reasonably available.

Not covered:

• Air Ambulance unless medically necessary and no other transport is reasonably available.

All charges

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

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

• 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

In-network:

• Inpatient professional - Deductible, then 20% of plan allowance
• Office - No copay
• Outpatient Professional Services- $35 copay

Out-of-network:

• Inpatient professional - Deductible, then 30% of plan allowance
• Office/Outpatient Professional Services - $80 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:

• Deductible, then 20% of plan allowance

Out-of-network:

• Deductible, then 30% 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:

• Calendar year deductible applies
• $100 for non-surgical hospital outpatient admissions

Out-of-network:

• Calendar year deductible applies
• $150 copay in the outpatient department of a hospital

•  Services that are not part of a preauthorized approved treatment plan.

All charges

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, deductible, 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 administration of covered medications.
• Drugs for sexual dysfunction (Subject to dosage limitations)
• 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)
  • No deductible for select generic drugs for treatment of asthma, blood pressure, cholesterol, depression and diabetes
  • Specialty drugs are limited to a 34-day supply for the first initial fill

Retail up to 34-day supply per copay:
Select Generics - No deductible and $0 
Tier 1 generics - Deductible, then $0 
Tier 2 preferred brand - Deductible, then $50
Tier 3 non-preferred brand - Deductible, then $75
Tier 4 preferred specialty - Deductible, then $100 
Tier 5 non-preferred specialty - Deductible, then $150 

Preferred and non-preferred brand Insulin - No deductible, then $30 copay

Opioid Reversal Agents- Deductible, then $0

Maintenance Drugs up to 90-day supply per copay:
Select Generics - No deductible and $0 
Tier 1 generics - Deductible, then $0 
Tier 2 preferred brand - Deductible, then $100
Tier 3 non-preferred brand - Deductible, then $150
Tier 4 preferred specialty - Deductible, then $200 
Tier 5 non-preferred specialty - Deductible, then $300 

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.

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/pshbp for any updates to this list and for additional information on how these items are covered.

Nothing: when prescribed by a healthcare professional and filled by a network pharmacy.

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories 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. A response will be provided within 24hrs of receiving the completed Exception Request Form. 

• If you have difficulty accessing contraceptive coverage or other reproductive healthcare you can contact contraception@opm.gov.

• Reimbursement for over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits see Section 5(a)

No copay

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Medical supplies such as dressings and antiseptics
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them, except as listed above
• Nonprescription medications unless specifically indicated elsewhere 
• Fertility drugs that are not deemed medically necessary.

Note:  Drugs that do not require a prescription by Federal law (Over-the-counter medications) that are not part of the preventive drug benefit.  Listed preventive care over-the-counter drugs can be submitted only if the member presents a prescription form completed by an authorized provider.

All Charges

The following are covered:

Preventive Medications with USPSTF A and B recommendations. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to 
www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

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.

Nothing: when prescribed by a healthcare professional and filled by a network pharmacy.

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.

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a network pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/.

Deductible, then $0 copay

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Medical supplies such as dressings and antiseptics
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them, except as listed above
• Nonprescription medications unless specifically indicated elsewhere 
• Fertility drugs that are not deemed medically necessary.

Note:  Drugs that do not require a prescription by Federal law (Over-the-counter medications) that are not part of the preventive drug benefit.  Listed preventive care over-the-counter drugs can be submitted only if the member presents a prescription form completed by an authorized provider.

All charges