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CareFirst SBC ID: SBC20160816AnneArundelCountyGovernmentEPON012017
Common
Medical Event
Services You May Need
Your cost if you use a
Limitations & Exceptions
Participating
Provider
Non-
Participating
Provider
More information about
prescription drug
coverage
is available at
www.caremark.com
Specialty drugs
Not covered
Not covered
Specialty drugs are only provided by Caremark
Specialty Drug Services
1-800-237-2767
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)
$25 copay
Not covered
–––––––––––none––––––––––
Physician/surgeon fees
$15 copay
Not covered
–––––––––––none––––––––––
If you need immediate
medical attention
Emergency room services
$75 copay
$75 copay
Copay waived if admitted
Limited to Emergency Services or unexpected,
urgently required services; Additional
professional charges may apply
Emergency medical transportation
No member liability
Not covered
Prior authorization is required for air
ambulance services, except for Medically
Necessary air ambulance services in an
emergency
Urgent care
$35 copay
$35 copay
Limited to unexpected, urgently required
services
If you have a hospital
stay
Facility fee (e.g., hospital room)
Deductible;0% coinsurance
Not covered
Prior authorization is required
Physician/surgeon fee
Deductible;0% coinsurance
Not covered
–––––––––––none––––––––––
CareFirst SBC ID: SBC20160816AnneArundelCountyGovernmentEPON012017
Common
Medical Event
Services You May Need
Your cost if you use a
Limitations & Exceptions
Participating
Provider
Non-
Participating
Provider
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health outpatient services
Office Visits:
$15 copay
Office Visits:
Not covered
For treatment at an Outpatient Hospital
Facility, an additional professional charge may
apply
Mental/Behavioral health inpatient services
Deductible;0% coinsurance
Not covered
Prior authorization is required; Additional
professional charges may apply
Requires pre-authorization from Magellan 1-
800-245-7013
Substance use disorder outpatient services
Office Visits:
$15 copay
Office Visits:
Not covered
For treatment at an Outpatient Hospital
Facility, an additional professional charge may
apply
Substance use disorder inpatient services
Deductible;0% coinsurance
Not covered
Prior authorization is required; Additional
professional charges may apply
Requires pre-authorization from Magellan 1-
800-245-7013
If you are pregnant
Prenatal and postnatal care
No member liability
Not covered
For routine pre/postnatal office visits only.
For non-routine obstetrical care or
complications of pregnancy, cost sharing may
apply.
Delivery and all inpatient services
Deductible;0% coinsurance
Not covered
Additional professional charges may apply