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CareFirst SBC ID: SBC20160816AnneArundelCountyGovernmentPOSN012017
Do I need a referral to
see a specialist?
No but you must use a
provider within the Blue
Choice network
No but you must use a
provider within the Blue
Preferred network
No
Option 1: You can see the specialist you choose without
permission from this plan.
Option 2: You can see the specialist you choose without
permission from this plan.
Option 3: You can see the specialist you choose without
permission from this plan.
Are there services this
plan doesn’t cover?
Yes
Yes
Yes
Option 1: Some of the services this plan doesn’t cover are listed on page 10.
See your policy or plan document for additional information about excluded
services.
Option 2: Some of the services this plan doesn’t cover are listed on page 10.
See your policy or plan document for additional information about excluded
services.
Option 3: Some of the services this plan doesn’t cover are listed on page 10.
See your policy or plan document for additional information about excluded
services.
Common
Medical Event
Services You May Need
Your cost if you use a
Limitations & Exceptions
Option 1
Option 2
Option 3
Participating Provider
Participating
Provider
Non-Participating
Provider
If you visit a health
care provider’s office
or clinic
Primary care visit to treat an injury
or illness
$15 copay
$25 copay
30% coinsurance subject
to deductible
For treatment at an Outpatient Hospital
Facility, an additional charge may apply
Specialist visit
$35 copay
$50 copay
30% coinsurance subject
to deductible
For treatment at an Outpatient Hospital
Facility, an additional charge may apply
Other practitioner office visit
$35 copay for Chiropractor
and Acupuncture Services
$50 copay for
Chiropractor and
Acupuncture Services
30% coinsurance subject
to deductible for
Chiropractor and
Acupuncture Services
For treatment at an Outpatient Hospital
Facility, an additional charge may apply
Retail Health Clinic
$15 copay
$25 copay
30% coinsurance subject
to deductible
For treatment at an Outpatient Hospital
Facility, an additional charge may apply
Preventive
care/screening/immunization
No member liability
No member liability
30% coinsurance subject
to deductible
Some services may have limitations or
exclusions based on your contract
If you have a test
Diagnostic test (x-ray, blood work)
Facility:
5% coinsurance subject to
deductible
Office:
No member liability
Facility:
Deductible; 5%
coinsurance
Office:
No member liability
Facility:
5% coinsurance subject
to deductible
Office:
No copay, coinsurance
or deductible
Option 1 In-Network Lab Test benefits
apply only to tests performed at LabCorp.
For services provided at an Outpatient
Hospital Facility, a higher charge may
apply
Imaging (CT/PET scans, MRIs)
5% coinsurance subject to
deductible
Facility:
Deductible; 5%
coinsurance
Office:
No member liability
Facility:
5% coinsurance subject
to deductible
Office:
No copay, coinsurance
or deductible
For services provided at an Outpatient
Hospital Facility, a higher charge may
apply
•
Co-payments
are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
•
Co-insurance
is
your
share of the costs of a covered service, calculated as a percent of the
allowed amount
for the service. For example, if the plan’s
allowed amount
for an overnight hospital stay is $1,000, your c
o-insurance
payment of 20% would be $200. This may change if you haven’t met
your
deductible
.
•
The amount the plan pays for covered services is based on the
allowed amount
. If an out-of-network
provider
charges more than the
allowed
amount
, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the
allowed
amount
is $1,000, you may have to pay the $500 difference. (This is called
balance billing
.)
•
This plan may encourage you to use participating
providers
by charging you lower
deductibles
,
co-payments
and
co-insurance
amounts.