MEDICAL BENEFITS Blue Preferred PPO Plan Highlights • • • •
Utilizes the national BlueCard PPO network Traditional PPO with lower deductible To locate an in-network doctor visit www.member.carefirst.com For out-of-network coverage, the allowed benefit is what CareFirst would have paid an in-network provider in the same area for the service. Your out-of-network provider can bill you the difference between what CareFirst pays and their actual charges.
CareFirst PPO Amounts shown are what the member will pay In-Network
Out-of-Network
$300 Ind | $600 Fam
$600 Ind | $1,200 Fam
$1,500 Ind | $3,000 Fam
$3,000 Ind | $6,000 Fam
No Charge No Charge No Charge $20 Copay $20 Copay $20 Copay
20% of Allowed Benefit Deductible then 20% of Allowed Benefit 0% of Allowed Benefit Deductible then 20% of Allowed Benefit Deductible then 20% of Allowed Benefit Deductible then 20% of Allowed Benefit
Diagnostic, Lab and X-ray
Deductible then No Charge
Deductible then 20% of Allowed Benefit
Imaging: CT, PET scan, MRIs
Deductible then No Charge
Deductible then 20% of Allowed Benefit
$40 Copay
Deductible then 20% of Allowed Benefit
Deductible Out-of-Pocket Maximum - Medical & Rx Preventive Services Well-Child Care (Exams & Immunizations) Adult Physical Exam (including routine GYN) Cancer Screenings (at set ages) & Pap Tests Physicians Office Visit - PCP or Specialist Physical, Speech & Occupational Therapy Chiropractic
Urgent Care Facility Hospital Emergency Room
Deductible then $150 Copay (copay waived if admitted)
Hospital Facility Services
Deductible then $250 Copay
Deductible then 20% of Allowed Benefit
Outpatient Facility Services
Deductible then $100 Copay
Deductible then 20% of Allowed Benefit
Prescription Coverage Tier I – Generic
$10 Copay
Tier II - Preferred Brand
$25 Copay
Tier III - Non-Preferred Brand
$45 Copay
Tier IV - Specialty Preferred Brand
$25 Copay
Tier V- Specialty Non-Preferred Brand
$45 Copay
90-Day Maintenance
2 X Retail Copay
Medical Per Pay Costs (2x for monthly cost) Employee Only
Employee & Spouse
Employee & Child(ren)
Employee & Family
Employee Contribution
$50.00
$80.00
$70.00
$87.50
SANS Contribution
$345.77
$829.71
$661.07
$1,021.47
New in 2022- Medical will no longer be bundled with dental. If you want medical and dental, you will need to elect both separately. Overall total costs will remain the same in 2022.
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