Open Enrollment 2018

Your cost if you use a

Common Medical Event

Services You May Need

Limitations & Exceptions

Non-Participating Provider

Participating Provider

For all prescription drugs: Prior authorization may be

Generic drugs

Deductible, then $15 co-pay

Paid as In-Network

required for certain drugs; No Charge for preventive drugs or contraceptives; Copay applies to up to 34-day supply; Up to 90-day supply of maintenance drugs is 2 copays Specialty Drugs: Participating Providers: covered when purchased through the Exclusive Specialty Pharmacy Network Non-Participating Providers: Not Covered

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.carefirst.com

Preferred brand drugs

Deductible, then $35 co-pay

Paid as In-Network

Non-preferred brand drugs

Deductible, then $60 co-pay

Paid as In-Network

Deductible, then 50% of Allowed Amount up to a maximum payment of $75 Ambulatory Surgery Center: Deductible, then No Charge Outpatient Hospital Facility: Deductible, then No Charge

Specialty drugs

Not Covered

Facility fee (e.g., ambulatory surgery center)

Not Covered

None

If you have outpatient surgery

Physician/surgeon fees

Deductible, then No Charge

Not Covered

None

Co-pay waived if admitted; Limited to Emergency Services or unexpected, urgently required services Prior authorization is required for air ambulance services, except for Medically Necessary air ambulance services in an emergency Limited to unexpected, urgently required services

Emergency room services

Deductible, then $100 co-pay Paid as In-Network

If you need immediate medical attention

Emergency medical transportation

Deductible, then No Charge

Paid as In-Network

Urgent care

Deductible, then No Charge

Paid as In-Network

Page 3 of 10

CareFirst SBC ID: SBC20170403MANBHHMMX98RXCMMX90N012017