Open Enrollment 2018

Your cost if you use a

Common Medical Event

Services You May Need

Limitations & Exceptions

Non-Participating Provider

Participating Provider

Home health care

Deductible, then No Charge

Not Covered

Prior authorization is required

Limited to 30 visits/condition/ benefit period

Rehabilitation services

Deductible, then No Charge

Not Covered

Prior authorization is required; Limited to Members under the age of 19

Habilitation services

Deductible, then No Charge

Not Covered

If you need help recovering or have other special health needs

Skilled nursing care

Deductible, then No Charge

Not Covered

Prior authorization is required

Prior authorization is required for specified services. Please see your contract. Prior authorization is required; Limited to a maximum 180 day Hospice Eligibility Period

Deductible, then 25% of Allowed Benefit Inpatient Care: Deductible, then No Charge Outpatient Care: Deductible, then No Charge

Durable medical equipment

Not Covered

Hospice service

Not Covered

$10 co-pay per visit at Participating Vision Providers Not Covered

Eye exam

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: SBC20170403MANBHHMMX98RXCMMX90N012017