CareFirst BlueCross BlueShield Health Benefits
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Choice + In-Area Plans
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Out-of-Area Plans
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Features
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Option 1
(HMO)
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Option 2
(PPO)
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Option 3 (Indemnity)
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Choice of Physicians and Hospitals
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Must select a primary care physician (from Option 1 Directory)
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Self refer to PPO network physician (From Option 2 Directory)
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Can use a physician of your choice
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Can use a non-network physician of your choice
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Annual Deductible
Individual
Family
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None
None
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$100 per calendar year
$300 per calendar year
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$300 per calendar year
$600 per calendar year
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$50 per calendar year
$150 per calendar year
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Annual Out-of-Pocket Maximum
Individual
Family
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None
None
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$500
$1000
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$1000
$2000
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$750
$1500
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Lifetime Maximum
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Unlimited
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Unlimited
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Unlimited
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Unlimited
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Office Visit Co-payment
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$10 Primary Care Physician
$20 Specialist
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$20
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20% coinsurance, after deductible
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15% of plan allowance, subject to the deductible
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Coinsurance
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$0
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90% of plan allowance
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80% of usual, customary, and reasonable allowance
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85% of plan allowance
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Participating Providers
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May not bill you for the balance
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Non-participating providers
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May bill you for the balance
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Caremark Prescription Benefits
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Features
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Pharmacy
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Mail Order/Maintenance Choice
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Supply Limit per prescription
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Up to a 34-day supply
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Up to a 90-day supply
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Generic drugs co-pay
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$5
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$10
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Preferred drugs co-pay
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$15
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$30
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Non-preferred drugs co-pay
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$25
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$50
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CareFirst BlueVision Benefits
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Features
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In-Network
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Out-of-Network
Reimbursed up to:
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Complete Eye Exam
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Free
(once every 12 months)
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$30
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Single Vision Lens
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See brochure
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$40
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Bifocal Lens
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See brochure
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$60
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Trifocal Lens
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See brochure
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$80
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Frames
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Once every 24 months
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Once every 24 months
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Contact Lenses
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See brochure for full explanation (Vision Brochure)
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Aetna Dental Benefits
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Features
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Dental PPO
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Annual Deductible
Individual
Family
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$50 per calendar year
$100 per calendar year
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Covered Services paid at 100%
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Such as one oral exam every six months, X-rays, cleaning, fillings, and extractions
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