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Summary of Benefits and Coverage: What this Plan Covers & What it Costs at www.carefirst.com or by calling 1-855-258-6518. Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an outofpocket limit on my expenses? What is not included in the outofpocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesnt cover? Answers For Participating Providers $0 For Non-Participating Providers $1,000 person/ $2,000 family Yes. $25 for Participating Providers $50 for Non-Participating Providers for Pediatric Dental coverage. There are no other specific deductibles. Yes. For Participating Providers $2,000 person/ $4,000 family For Non-Participating Providers $4,000 person/ $8,000 family Premiums, balance-billed charges, and health care this plan doesn't cover. No. Yes. For a list of preferred providers, see www.carefirst.com or call 1-855-258-6518. No. Yes.
Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual | Plan Type: POS
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document
Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they dont count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesnt cover are listed on page 5. See your policy or plan document for additional information about excluded services.
Questions: If you are a member please call the number on your ID card or visit www.carefirst.com. Otherwise, please call 1-855-258-6518. If you arent clear about any of the underlined terms used in this form, see the Glossary at www.carefirst.com/sbcg. CareFirst SBC ID: SBC20130910MANHCUDBN8ARXXDBN81N012014 Page 1 of 9
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance 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 plans
allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you havent 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, copayments and coinsurance amounts. Common Medical Event Your cost if you use a Participating Non-Participating Provider Provider Deductible, then $30 No Charge co-pay per date of service $30 co-pay per date of Deductible, then $30 service co-pay per date of service Deductible, then $30 $30 co-pay per date of co-pay per date of service service for Chiropractic for Chiropractic Deductible, then No No Charge Charge Deductible, then No No Charge Charge Deductible, then No No Charge Charge No Charge $45 co-pay $100 co-pay $200 co-pay $30 co-pay per date of service No Charge $45 co-pay $100 co-pay $200 co-pay Deductible, then $100 co-pay per date of service
Services You May Need Primary care visit to treat an injury or illness
Limitations & Exceptions None None None None None None Covers up to a 34-day supply Covers up to a 34-day supply Covers up to a 34-day supply Covers up to a 34-day supply None
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.carefirst.com If you have outpatient surgery
Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center)
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Your cost if you use a Participating Non-Participating Provider Provider $30 co-pay per date of service $200 co-pay per visit $50 co-pay per date of service $50 co-pay per date of service $150 co-pay per day $30 co-pay per date of service No Charge $150 co-pay per day Deductible, then $100 co-pay per date of service $200 co-pay per visit $50 co-pay per date of service $50 co-pay per date of service Deductible, then $400 co-pay per day Deductible, then $100 co-pay per date of service Deductible, then $30 co-pay per date of service Deductible, then $400 co-pay per day Deductible, then $30 co-pay per date of service Deductible, then $400 co-pay per day Deductible, then $30 co-pay per date of service Deductible, then $400 co-pay per day
Limitations & Exceptions None Co-pay waived if admitted Limited to Emergency Services Prior authorization is required for air ambulance services, except for Medically Necessary air ambulance services in an emergency None Requires prior authorization None None Requires prior authorization None Requires prior authorization. For Participating Providers: Preventive Prenatal Care is provided at No Charge, and includes 1 postnatal visit/ delivery None
Urgent care If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services
Substance use disorder outpatient services No Charge Substance use disorder inpatient services $150 co-pay per day $30 co-pay per date of service $150 co-pay per day
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Your cost if you use a Participating Non-Participating Provider Provider No Charge $30 co-pay per date of service $30 co-pay per date of service Deductible, then $100 co-pay per date of service Deductible, then $30 co-pay per date of service Deductible, then $30 co-pay per date of service Deductible, then $100 co-pay per service Deductible, then 40% of Allowed Benefit
Limitations & Exceptions Limited to 90 visits/episode of care Requires prior authorization None Requires prior authorization Benefits available for Members age 21 and older are limited to 30 visits/ condition/ benefit period Limited to 60 days/benefit period Requires prior authorization Prior authorization is required for specific services. Please see your contract. Requires prior authorization Inpatient Hospice Services: Limited to 60 days per Hospice Eligibility Period Outpatient Hospice Services: For Participating Providers: No Charge For Non-Participating Providers: Deductible, then $100 co-pay per date of service Limited to 180 day Hospice Eligibility Period Limited to members up to age 19 Limited to 1 visit/benefit period Limited to members up to age 19 Limited to 1 set of glasses/lenses per benefit period Limited to members up to age 19 Page 4 of 9
Habilitation services
Hospice service
Eye exam If your child needs dental or eye care Glasses Dental check-up
Member pays expenses in excess of the Pediatric Vision Allowed Benefit of $40 Allowances available for glasses/lenses 20% of Allowed Benefit
Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic Most coverage provided outside the United States. Non-emergency care when traveling outside the U.S. Routine eye care (Adult)
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OR
For more information on your rights to continue coverage, contact the insurer at 1-855-258-6518. You may also contact your state insurance department at Maryland -1-800-492-6116 or http://www.mdinsurance.state.md.us DC 1-877-685-6391 or www.disb.dc.gov Virginia 1-877-310-6560 or www.scc.virginia.gov/boi
For group health coverage subject to ERISA you may also contact the Department of Labors Employee Benefits Security Administration at 1-866444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
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To see examples of how this plan might cover costs for a sample medical situation, see the next page.
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Having a baby
(normal delivery) Amount owed to providers: $7,540 Plan pays: $7,240 Patient pays: $300 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540 $0 $150 $0 $150 $300
Note: These coverage examples calculations are based on Individual Coverage Tier numbers for this plan.
Note: These numbers assume the patient is participating in our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may be higher. For more information about the diabetes wellness program, please contact: www.carefirst.com .
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costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.
estimators. You cant use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own Questions: If you are a member please call the number on your ID card or visit www.carefirst.com. Otherwise, please call 1-855-258-6518. If you arent clear about any of the underlined terms used in this form, see the Glossary at www.carefirst.com/sbcg. CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. ' Registered trademark of CareFirst of Maryland, Inc. CareFirst SBC ID: SBC20130910MANHCUDBN8ARXXDBN81N012014 Page 9 of 9