Summary of Benefits and Coverage: What This Plan Covers & What You Pay For Covered Services

HealthyBlue Advantage Platinum 500 Coverage Period: 01/01/2020 - 12/31/2020

Coverage for: Individual | Plan Type: POS

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible , provider,
or other underlined terms see the Glossary. You can see the Glossary at www.carefirst.com/sbcg or call 1-855-258-6518 to request a copy. For more information about your
coverage, or to get a copy of the complete terms of coverage, please visit http://content.carefirst.com/sbc/contracts/HDUVB002RXXVB215.pdf.
Important Questions Answers Why this Matters:
Generally, you must pay all the costs from provider up to the deductible amount before this
In-Network: $500 individual/ $1,000 plan begins to pay. If you have other family member(s) on the plan, each family member may
What is the overall
family; Out-of-Network: $1,000 need to meet their own individual deductible, OR all family members may combine to meet the
deductible?
individual/ $2,000 family. overall family deductible before the plan begins to pay, depending upon plan coverage. Please
refer to your contract for further details.
Yes, all In-Network preventive care
services, as well as the following
(non-hospital facilities only, when
applicable): Primary care, Specialist,
This plan covers some items and services even if you haven’t yet met the deductible amount.
Are there services Retail health, Diagnostic testing,
But, a copayment or coinsurance may apply. For example, this plan covers certain preventive
covered before you meet Prescription drugs, Outpatient
services without cost sharing and before you meet your deductible. See a list of covered
your deductible ? surgery, Emergency room,
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ .
Emergency medical transportation,
Urgent care, Mental Health office
visit, Home health, Rehabilitation
services, Hospice.
Yes. Pediatric Dental: In-Network:
Are there other $25 individual; Out-of-Network: $50 You must pay all of the costs for these services up to the specific deductible amount before this
deductibles for specific individual. plan begins to pay for these services.
services? There are no other specific
deductibles.
Medical and Prescription Drug The out-of-pocket limit is the most you could pay in a plan year for covered services. If you
combined: In-Network: $1,500 have other family member(s) on the plan, each family member may need to meet their own
What is the out-of-pocket
individual/ $3,000 family; out-of-pocket limits, OR all family members may combine to meet the overall family
limit for this plan?
Out-of-Network: $3,000 individual/ out-of-pocket limit, depending upon plan coverage. Please refer to your contract for further
$6,000 family. details.

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.

SBC ID: SBC20190929MANHDUVB002RXXVB215N012020 Page 1 of 8

 Premiums, balance-billed charges,
What is not included in
and health care this plan does not Even though you pay these expenses, they don't count toward the out-of-pocket limit.
the out-of-pocket limit?
cover.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network.
Yes. See www.carefirst.com or call You will pay the most if you use an out-of-network provider, and you might receive a bill from a
Will you pay less if you
1-855-258-6518 for a list of provider provider for the difference between the provider’s charge and what your plan pays (balance
use a network provider?
network. billing). Be aware, your network provider might use an out-of-network provider for some
services (such as lab work). Check with your provider before you get services.
Do I need a referral to see
No. You can see the specialist you choose without a referral.
a specialist?

What You Will Pay

Common In-Network Provider Out-of-Network Provider Limitations, Exceptions & Other
Services You May Need
Medical Event (You will pay the least) (You will pay the most) Important Information
Provider: No Charge Provider: Deductible, then
If a service is rendered at a Hospital
Primary care visit to treat an Hospital Facility: $50 copay per visit
Facility, the additional Facility charge may
injury or illness Deductible, then $50 Hospital Facility: Deductible,
apply
copay per visit then $150 copay per visit
Provider: $30 copay per
Provider: Deductible, then
visit If a service is rendered at a Hospital
$50 copay per visit
Specialist visit Hospital Facility: Facility, the additional Facility charge may
Hospital Facility: Deductible,
If you visit a health Deductible, then $50 apply
then $150 copay per visit
care provider’s office or copay per visit
clinic Deductible, then $50 copay
Retail Health Clinic No Charge None
per visit
Preventive care/screening/ Some services may have limitations or
No Charge Deductible, then No Charge
immunization exclusions based on your contract

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 What You Will Pay
Common In-Network Provider Out-of-Network Provider Limitations, Exceptions & Other
Services You May Need
Medical Event (You will pay the least) (You will pay the most) Important Information
LabTest: Non-Hospital:
LabTest: Non-Hospital: Deductible, then $50 copay
No Charge per visit
Hospital: Deductible, Hospital: Deductible, then
Diagnostic test (x-ray, blood then $15 copay per visit $80 copay per visit
None
work) XRay: Non-Hospital: No XRay: Non-Hospital:
Charge Deductible, then $50 copay
Hospital: Deductible, per visit
then $30 copay per visit Hospital: Deductible, then
If you have a test $80 copay per visit
Non-Hospital: $100 Non-Hospital: Deductible,
copay per visit then $150 copay per visit
Imaging (CT/PET scans, MRIs) None
Hospital: Deductible, Hospital: Deductible, then
then $200 copay per visit $250 copay per visit
For all prescription drugs:
Generic drugs No Charge Paid As In-Network
Prior authorization may be required for
If you need drugs to treat certain drugs; No Charge for preventive
Preferred brand drugs $45 copay Paid As In-Network
your illness or condition drugs or contraceptives; Copay applies to
More information about up to 30-day supply; Up to 90-day supply
Non-preferred brand drugs $65 copay Paid As In-Network
prescription drug of maintenance drugs is 2 copays
coverage is available at 50% of Allowed Benefit
www.carefirst.com/rx Preferred Specialty drugs up to a maximum Paid As In-Network
payment of $100
50% of Allowed Benefit
Non-preferred Specialty drugs up to a maximum Paid As In-Network
payment of $150
Non-Hospital: $100 Non-Hospital: Deductible,
Facility fee (e.g., ambulatory copay per visit then $200 copay per visit
None
surgery center) Hospital: Deductible, Hospital: Deductible, then
If you have outpatient then $200 copay per visit $300 copay per visit

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 What You Will Pay
Common In-Network Provider Out-of-Network Provider Limitations, Exceptions & Other
Services You May Need
Medical Event (You will pay the least) (You will pay the most) Important Information
surgery Non-Hospital: $30 copay
Non-Hospital & Hospital:
per visit
Physician/surgeon fees Deductible, then $50 copay None
Hospital: Deductible,
per visit
then $30 copay per visit
Limited to Emergency Services or
unexpected, urgently required services;
Emergency room care $200 copay per visit Paid As In-Network
Additional professional charges may apply;
Copay waived if admitted
Prior authorization is required for air
If you need immediate Emergency medical
$30 copay per visit Paid As In-Network ambulance services, except when
medical attention transportation
Medically Necessary in an emergency
Limited to unexpected, urgently required
Urgent care $50 copay per visit Paid As In-Network
services
Facility fee (e.g., hospital Deductible, then $500 Deductible, then $600 copay
Prior authorization is required
If you have a hospital room) copay per admission per admission
stay Deductible, then $30 Deductible, then $50 copay
Physician/surgeon fee None
copay per visit per visit
If you have mental Outpatient services Office Visit: Deductible, then For treatment at an Outpatient Hospital
Office Visit: No Charge
health, behavioral $50 copay per visit Facility, additional charges may apply
health, or substance
Deductible, then $500 Deductible, then $600 copay Prior authorization is required; Additional
abuse services Inpatient services
copay per admission per admission professional charges may apply

For routine pre/postnatal office visits only.

Deductible, then $50 copay For non-routine obstetrical care or
Office visits No Charge
per visit complications of pregnancy, cost sharing
may apply.
Childbirth/delivery professional Deductible, then $30 Deductible, then $50 copay
If you are pregnant None
services copay per visit per visit

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 What You Will Pay
Common In-Network Provider Out-of-Network Provider Limitations, Exceptions & Other
Services You May Need
Medical Event (You will pay the least) (You will pay the most) Important Information
Childbirth/delivery facility Deductible, then $500 Deductible, then $600 copay
None
services copay per admission per admission
Deductible, then $50 copay Prior authorization is required; 100
Home health care No Charge
per visit visits/benefit period
Provider: $30 copay per
Provider: Deductible, then
visit If a service is rendered at a Hospital
$50 copay per visit
Rehabilitation services Hospital Facility: Facility, the additional Facility charge may
Hospital Facility: Deductible,
Deductible, then $50 apply; 30 visits/therapy type/benefit period
then $150 copay per visit
copay per visit
Provider: $30 copay per
Provider: Deductible, then Prior authorization is required; If a service
visit
$50 copay per visit is rendered at a Hospital Facility, the
Habilitation services Hospital Facility:
Hospital Facility: Deductible, additional Facility charge may apply; 30
If you need help Deductible, then $50
then $150 copay per visit visits/therapy type/benefit period
recovering or have other copay per visit
special health needs Deductible, then $30 Deductible, then $50 copay Prior authorization is required; 100
Skilled nursing care
copay per admission per admission days/admission
Deductible, then 25% of Deductible, then 45% of Prior authorization is required for specified
Durable medical equipment
Allowed Benefit Allowed Benefit services. Please see your contract.
Inpatient Care: Deductible,
Inpatient Care: No Prior authorization is required; For
then $50 copay per
Charge Participating Providers and
Hospice services admission
Outpatient Care: No Non-Participating Providers (combined):
Outpatient Care: Deductible,
Charge Limited to a maximum of 180 days
then $50 copay per visit
Member pays expenses in
Limited to Member up to age 19; 1
Children's eye exam No Charge excess of the Pediatric
visit/benefit period
Vision Allowed Benefit
If your child needs dental No Charge for Allowances available for Limited to Members up to age 19; 1 set of
Children's glasses
or eye care glasses/lenses glasses/lenses glasses/lenses per benefit period

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 What You Will Pay
Common In-Network Provider Out-of-Network Provider Limitations, Exceptions & Other
Services You May Need
Medical Event (You will pay the least) (You will pay the most) Important Information
Limited to Members up to age 19; 2
Children's dental check-up No Charge 20% of Allowed Benefit
visits/benefit period

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Cosmetic surgery • Infertility treatment • Routine foot care
• Dental care (Adult) • Long-term care • Weight loss programs
• Hearing aids • Routine eye care (Adult)

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Abortion, except in limited circumstances • Chiropractic care • Private-duty nursing
• Acupuncture • Coverage provided outside the United States.
See www.carefirst.com
• Bariatric surgery • Non-emergency care when traveling outside the
U.S.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: Department of Labor Employee Benefits Security Administration, http://www.dol.gov/ebsa/healthreform, or call 1-866-444-EBSA (3272); or
Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, http://www.cciio.cms.gov, or call 1-877-267-2323 x61565.
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more
information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or
assistance, contact: Department of Labor Employee Benefits Security Administration, http://www.dol.gov/ebsa/healthreform, or call 1-866-444-EBSA (3272); or
Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, http://www.cciio.cms.gov, or call 1-877-267-2323 x61565.

Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from
the requirement that you have health coverage for that month.

SBC ID: SBC20190929MANHDUVB002RXXVB215N012020 Page 6 of 8

Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
–––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––

SBC ID: SBC20190929MANHDUVB002RXXVB215N012020 Page 7 of 8

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles,
copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different
health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe's type 2 Diabetes Mia's Simple Fracture
(9 months of in-network pre-natal care and a (a year of a routine in-network care of a (in-network emergency room visit and follow
hospital delivery) well-controlled condition) up care)

The plan’s overall deductible $500 The plan’s overall deductible $500 The plan’s overall deductible $500
Specialist Copayment $30 Specialist Copayment $30 Specialist Copayment $30
Hospital (facility) Copayment $500 Hospital (facility) Copayment $500 Hospital (facility) Copayment $200
Other Copayment $0 Other Coinsurance 25% Other Copayment $0

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $500 Deductibles $500 Deductibles $500
Copayments $1,000 Copayments $645 Copayments $410
Coinsurance $0 Coinsurance $308 Coinsurance $63
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $10 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $1,510 The total Joe would pay is $1,453 The total Mia would pay is $973
The plan would be responsible for the other costs of these EXAMPLE covered services.
SBC ID: SBC20190929MANHDUVB002RXXVB215N012020 Page 8 of 8
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