Open Enrollment 2018

Your cost if you use a

Common Medical Event

Services You May Need

Limitations & Exceptions

Non-Participating Provider

Participating Provider

Prior authorization is required; Limited to 40 visits/benefit period Limited to 30 visits/condition/ benefit period Prior authorization is required; Limited to Members under the age of 19

Home health care

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

Rehabilitation services

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

Habilitation services

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

If you need help recovering or have other special health needs

Skilled nursing care

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

Prior authorization is required

Prior authorization is required for specified services. Please see your contract.

Deductible, then 25% of Allowed Benefit

Deductible, then 50% of Allowed Benefit

Durable medical equipment

Inpatient Care: Deductible, then 20% of Allowed Benefit Outpatient Care: Deductible, then 20% of Allowed Benefit

Prior authorization is required; Limited to a maximum 180 day Hospice Eligibility Period; Inpatient Care Limited to 30 days per Member

Inpatient Care: Deductible, then No Charge Outpatient Care: Deductible, then No Charge

Hospice service

$10 co-pay per visit at Participating Vision Providers

Eye exam

Total charge minus $33

Limited to 1 visit/benefit period

If your child needs dental or eye care

Glasses

Not Covered

Not Covered

None

Dental check-up

Not Covered

Not Covered

None

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CareFirst SBC ID: SBC20170403MANBTHMMX98RXCMMX90N012017