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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 need help
recovering or have
other special health
needs
Home health care
5% coinsurance subject to
deductible
Deductible; 5%
coinsurance
5% coinsurance subject
to deductible
Option 2 and 3:
90 days of unlimited visits per Benefit
Period
Rehabilitation services
Facility:
5% coinsurance subject to
deductible
Office:
$35 copay
Facility:
5% coinsurance subject
to deductible
Office:
$50 copay
30% coinsurance subject
to deductible
For treatment at an Outpatient Hospital
Facility, an additional charge may apply
Rehabilitation Services includes Physical,
Speech and Occupational Therapies
Option 1: Limited to 100 combined visits
per benefit period
Option 2 and 3: Limited to 100 combined
visits per benefit period
Habilitation services
Facility:
5% coinsurance subject to
deductible
Office:
$35 copay
Facility:
5% coinsurance subject
to deductible
Office:
$50 copay
30% coinsurance subject
to deductible
Prior authorization is required after the
first visit
Limited to members under age 19
Skilled nursing care
5% coinsurance subject to
deductible
15% coinsurance subject
to deductible
30% coinsurance subject
to deductible
Option 2 and 3:
Limited to 120 days per Benefit Period
Durable medical equipment
5% coinsurance subject to
deductible
Deductible; 5%
coinsurance
Deductible; 5%
coinsurance
–––––––––––none–––––––––––
Hospice service
Inpatient care:
5% coinsurance subject to
deductible
Outpatient care:
5% coinsurance subject to
deductible
Inpatient care:
Deductible; 5%
coinsurance
Outpatient care:
Deductible; 5%
coinsurance
Inpatient care:
Deductible; 5%
coinsurance
Outpatient care:
Deductible; 5%
coinsurance
–––––––––––none–––––––––––
If your child needs
dental or eye care
Eye exam
Not covered
Not covered
Not covered
Routine vision services are not provided
by Blue Choice Triple Option Open
Access. Vision services are available with
separate enrollment in the VSP Vision
plan.
Glasses
Not covered
Not covered
Not covered
Routine vision services are not provided
by Blue Choice Triple Option Open
Access. Vision services are available with
separate enrollment in the VSP Vision
plan.
Dental check-up
Not covered
Not covered
Not covered
Routine Dental services are not provided
by Blue Choice HMO. Dental services are
available with separate enrollment in the
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
Cigna PPO Dental Plan or the Cigna
DHMO Dental Plan.
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover
(This isn’t a complete list. Check your policy or plan document for other excluded
services.)
•
Cosmetic surgery
•
Dental care
•
Long-term care
•
Routine eye care
•
Routine foot care
•
Weight loss programs
Other Covered Services
(This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
•
Acupuncture
•
Bariatric surgery
•
Chiropractic care
•
Hearing aids (Children & Adults)
•
Infertility treatment
•
Most coverage provided outside the United
States. See
www.carefirst.com
•
Non-emergency care when traveling outside the U.S.
•
Private-duty nursing