Summary of benefits and coverage fcps carefirst com

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Fairfax County Public Schools ? CareFirst Blue Choice Advantage

Coverage Period: 01/01/2019 ? 12/31/2019 Coverage for: Individual/Family | 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 more information about your coverage, or to get a copy of the complete terms of coverage, contact CareFirst at 1-800-296-0724. 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 view the Glossary at or call 1-800-296-0724 to request a copy. For more information about your coverage, or to get a copy of the complete terms of coverage, please visit fcps.

Important Questions

Answers

Why This Matters:

What is the overall deductible?

In-Network: $250 individual/$500 family; Out-of-Network: $500 individual/$1000 family

Are there services covered before you meet your deductible?

Yes. In-Network preventive care services.

Are there other deductibles

for specific services?

No.

Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at .

You don't have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

In-Network and Out-of-Network combined out of pocket maximum: $2,000 individual/$4,000 family Pharmacy: $1,500 Individual/$3,000 Family

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

Premiums, balance-billing charges, health care this plan doesn't cover, and penalties for failure to obtain pre-authorization for services. Copays and coinsurance for covered prescriptions apply to pharmacy out-of-pocket maximum.

Yes. See or call 800-2960724 for a list of Network providers.

Even though you pay these expenses, they don't count toward the out?of?pocket limit. Separate out-of-pocket maximums apply to medical and pharmacy benefits.

This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-ofnetwork provider for some services (such as lab work). Check with your provider before you get services.

No

You can see the specialist you choose without a referral.

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

If you visit a health care provider's office or clinic

If you have a test

Services You May Need

Primary care visit to treat an injury or illness

Specialist visit

Retail health clinic

What You Will Pay

Network Provider

Out-of-Network Provider

(You will pay the least) (You will pay the most)

$20 copay per visit

40% of Allowed Benefit

$40 copay per visit $20 copay per visit

40% of Allowed Benefit 40% of Allowed Benefit

Preventive care/screening/ immunization

No charge. Deductible does not apply.

40% of Allowed Benefit

Diagnostic test (x-ray, blood work)

No Charge

Imaging (CT/PET scans, MRIs)

Office (Non-Hospital) $75 copay per visit OP Facility (Hospital) $100 copay per visit

40% of Allowed Benefit 40% of Allowed Benefit

Limitations, Exceptions & Other Important Information

No visit limits.

Therapeutic services limited to 90 visit max, per therapy, per calendar year. None Age & frequency limits may apply. You may have to pay for services that aren't preventive. Ask you provider if the services needed are preventive. Then check with your plan will pay for. LabCorp is the participating provider for laboratory services inside the CareFirst service area. For participating labs outside the service area, see fcps.

None

Generic drugs

If you need drugs to treat your illness or condition

More information about prescription drug coverage

is available at .

Preferred brand drugs

Non-preferred brand drugs

Specialty drugs

Retail: $7/$14/$21 (30/60/90-day supply) Mail Order: $14 (up to 90 day supply)

20% subject to following maximums:

Retail: $50/$100/$150 (30/60/90-day supply)

Mail Order: $100 (up to 90-day supply)

Not Covered

20% of cost of drug, $50 max 30 day supply

Pay in full, then file claim for reimbursement. Reimbursement limited to amount plan would have paid if network pharmacy was used.

Not Covered

Must use CVS Specialty Pharmacy after first fill

Participants using a CVS retail pharmacy for maintenance medications may receive a 90 day supply for two retail copays. For plan details, see

(Employees/Non-Medicare retirees); Your plan uses a network of participating pharmacies and a formulary (a list of preferred covered medications). Some drugs may require preauthorization. If the necessary preauthorization is not obtained, the drug may not be covered.

Deductible does not apply to prescription coverage. Certain preventive medications covered for $0 copay.

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

If you have outpatient surgery

If you need immediate medical attention

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

Services You May Need

Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees

Emergency room care Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fees

Outpatient service es

Inpatient services

What You Will Pay

Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

$100 copay per visit

40% of Allowed Benefit

$20 PCP copay per visit $40 Spec copay per visit

$150 copay then 10% of Allowed Benefit

40% of Allowed Benefit

Paid as in Network if bona fide emergency

10% of Allowed Benefit

40% of Allowed Benefit

$40 copay per visit

$40 copay per visit

$150 admission copay, plus $100 copay per day (max 5 copays per admission)

$20 PCP copay per visit $40 Spec copay per visit

$20 copay per visit (office) $40 copay per visit (specialist). $100 copay facility charge (if applicable)

$150 admission copay, plus $100 copay per day (max 5 copays per admission)

$150 per admission copay then 40% of Allowed Benefit 40% of Allowed Benefit

40% of Allowed Benefit

40% of Allowed Benefit

Limitations, Exceptions & Other Important Information

Prior authorization may be required depending on type of service rendered.

$150 copay waived if admitted. No coverage for non-emergency use; prudent layperson rules & definitions apply. Must be medically necessary. If using a non-participating provider, may be required to pay in full & file for reimbursement.

Prior authorization is required for all inpatient admissions.

For treatment at an Outpatient Hospital Facility, facility charge may apply. Prior authorization is not required for Outpatient Therapy Visits.

Prior authorization is required for all inpatient hospital and treatment facility stays. Additional professional charges may apply

If you are pregnant

Office visits

Childbirth/delivery professional services Childbirth/delivery facility services

No Charge

40% of Allowed Benefit

$20 PCP copay per visit $40 Spec copay per visit

$150 admission copay, plus $100 copay per day (max 5 copays per admission)

40% of Allowed Benefit

$150 per admission copay then 40% of Allowed Benefit

Cost sharing does not apply for preventive services. Depending on the type of service, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Prior authorization required for maternity & newborn confinements that exceed the standard length of stay for normal vaginal delivery or C-Section.

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Home health care

$40 copay per visit

40% of Allowed Benefit

90 visits/calendar year; prior authorization is required

Inpatient rehab: 90 days per benefit period combined between in-network and out-of-network. Prior authorization required. Per admission copay may apply.

Rehabilitation services

$40 copay per visit/therapy

If you need help recovering or have other special health needs

Habilitation services

Skilled nursing care

$40 copay per visit/therapy

Hospital Facility: $150 admission copay, plus $100 copay per day (max 5 copays per admission)

Durable medical equipment $40 copay

If your child needs dental or eye care

Outpatient: $40 copay per visit

Hospice services

Children's eye exam Children's glasses Children's dental check-up

Hospital Facility: $150 admission copay, plus $100 copay per day (max 5 copays per admission)

$20 copay, not subject to deductible Standard glasses covered in full up to $130 allowance Not covered

40% of Allowed Benefit

40% of Allowed Benefit 40% of Allowed Benefit 40% of Allowed Benefit

Outpatient rehab: 90 days per illness per benefit period (PT, OT, ST combined and combined between in-network and out-of-network. UM approval required. If a service is rendered at a Hospital Facility, the additional Facility charge may apply.

Prior authorization is required. Coverage for Autism and Pervasive Development Disorder limited to ages 2-10. Other habilitative services covered as part of Early Intervention Program (birth to age 3). If a service is rendered at a Hospital Facility, the additional Facility charge may apply

Prior authorization is required. 120 days maximum per benefit period renewed when out of facility 60 consecutive days. $150 copay admission copay waived if transferred directly from inpatient facility

Prior authorization is required for certain durable medical equipment. Please see your Summary of Benefits for more information.

$150 per admission copay then 40% of Allowed Benefit

Prior authorization is required. Inpatient per admission copay waived if transferred directly from inpatient or skilled nursing facility.

Reimbursement up to $40

Reimbursement $40 $80

Not covered

Once every 12 months. Routine vision services not subject to deductible.

Lenses once per 12 months; frames once per 24 months; max $130 allowance

Not covered.

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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 Dental care (Adult and child)

Long-term care Routine foot care

Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

Acupuncture ? only if used by a physician in lieu of anesthesia

Bariatric surgery - subject to Utilization Management approval

Chiropractic care

Infertility treatment ? subject to Utilization Mgmt approval

Hearing aids ? only if result of accidental injury Non-emergency care when travelling outside the

US. See

Private-duty nursing ? outpatient only ? limited to 120 days per benefit period

Routine eye care (Adult)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. For more information on your rights to continue coverage, contact the plan at fcps.edu or 571-423-3200, Option 3. For non-federal governmental group health plans, contact the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or iio..

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 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 Health and Human Services, Center for Consumer Information and Insurance Oversight, , 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.

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.

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Language Access Services: [Spanish (Espa?ol): Para obtener asistencia en Espa?ol, llame al 1-855-258-6518.] [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-258-6518.] [Chinese (): 1-855-258-6518.] [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-258-6518.]

??????????????????????To see examples of how this plan might cover costs for a sample medical situation, see the next section.?????????????????????

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