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 Benefit up to a maximum payment of $75

Specialty drugs

Not Covered

Ambulatory Surgery Center: Deductible, then 20% of Allowed Benefit Outpatient Hospital Facility: Deductible, then 20% of Allowed Benefit

Ambulatory Surgery Center: Deductible, then No Charge Outpatient Hospital Facility: Deductible, then No Charge

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

None

If you have outpatient surgery

Physician/surgeon fees

Deductible, then No Charge Deductible, then 20% of Allowed Benefit

None

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

Emergency room services

Deductible, then $100 co-pay per visit

Paid as In-Network

If you need immediate medical attention

Emergency medical transportation

Deductible, then No Charge Deductible, then 20% of Allowed Benefit

Urgent care

Deductible, then No Charge Deductible, then 20% of Allowed Benefit

Page 3 of 10

CareFirst SBC ID: SBC20170403MANBTHMMX98RXCMMX90N012017