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/op false BlueChoice Advantage HSA/HRA Gold 1500 Integrated Deductible Summary of Benefits Services In-Network You Pay1 Out-of-Network You Pay1 ... is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are CareFirst BlueCross BlueShield offers several types of health plans. BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. 0 593 556 0 0 0 0 0 0 0 epsilon Bronze: Nationwide In-Network. /H [ 2063 307 ] 54 0 R /SA true Contract. Oral Chemo Drugs and Diabetic Supplies HSA - No charge* after deductible; HRA - No charge* Generic Drugs Deductible, then 30-day supply $10; Deductible, then 90-day supply $20 (maintenance drugs only) Preferred Brand Drugs11 Deductible, then 30-day supply $45; Deductible, then 90-day supply $90 (maintenance drugs only) Non-preferred Brand Drugs12 Deductible, then 30-day supply $65; … /Encoding 55 0 R The BlueChoice … In-Network: $1,500 / $3,000 BlueChoice HMO HSA/HRA 2000 Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO Questions: If you are a member please call the number on your ID card or visit www.carefirst.com. HealthyBlue Advantage HRA/HSA Integrated Deductible Summary of Benefits Services In-Network You Pay1,2 Out-of-Network You Pay1,3 ... by CareFirst BlueChoice, or the local Blue Cross and Blue Shield Plan, however, in certain circumstances, an allowance may be established by law. 0000018163 00000 n All States; All Territories, except Midway Islands. /Size 78 /ExtGState << Services In-Network You Pay1 Out-of-Network You Pay1. /Widths [ 537 278 0 0 0 0 0 0 0 0 /AIS false 0 2.0 HRA, HealthyBlue 2.0 HSA, HealthyBlue Advantage, HealthyBlue Advantage HRA and HealthyBlue Advantage HSA health care plans. delta Silver: Nationwide In-Network. Serving Maryland, the District of Columbia and portions of Virginia. If you want more detail about your coverage and … Please return this form to your employer. /SA false BlueChoice Advantage HRA Compatible, Option ____ BlueChoice Advantage HSA Compatible, Option ____ CHECK ALL APPLICABLE: Dental HMO Dental HMO Opt-Out Preferred Dental Traditional Dental BlueVision Plus. CareFirst does not exclude people or … • BlueChoice Advantage HSA/HRA Silver 3000 • BlueChoice Advantage Silver 5000 : Gold • BlueChoice Advantage HSA/HRA Gold 1500 • BlueChoice HMO Gold 1500 • BlueChoice Advantage Gold 1000 . << /ABCpdf 6109 Check any two boxes to compare those two plans. BlueChoice Advantage HSA/HRA Silver 2500. >> 18 0 obj << Example: Dr. Carson charges $100 to see a sick patient. Contract. /op true 0000009166 00000 n BlueChoice Advantage Option 4 Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: POS This is only a summary. << /CA 1 If you have our Blue Option SM Coverage (through the Affordable Care Act), visit www.BlueOptionSC.com.. Additional Provider Information: Find an independent lab in South Carolina through Quest Diagnostics and LabCorp.These are independent companies that provide lab services on behalf of BlueChoice HealthPlan. /Linearized 1 0000016054 00000 n Services In-Network You Pay1 Out-of-Network You Pay1 HOSPITALIZATION—MEMBERS ARE RESPONSIBLE FOR APPLICABLE PHYSICIAN AND FACILITY FEES Outpatient Facility Surgery (Freestanding Facility) Deductible, then $100 per visit Deductible, then 20% of Allowed Benefit 0 722 0 0 0 0 0 0 0 0 delta Silver: Nationwide In-Network. /T1_5 32 0 R /Info 17 0 R Employers decide what types of expenses are considered eligible. BlueChoice Advantage HSA/HRA Bronze 6000. 0 0 0 0 0 0 370 0 0 0 An HRA reimburses employees and their families for eligible medical expenses. Summary of Benefits and Coverage. 482 ] In-Range—no changes . 0000005355 00000 n 0000003366 00000 n Out-Network: $1,000 / $2,000. Office Hours Monday to Friday, 8 am to 5:30 pm Connect With Us 1225 Eye Street, NW, Suite 400, Washington, DC 20005 Phone: (202) 715-7576 TTY: 711 BlueChoice Advantage HSA/HRA : PM0011-1E (5/18) Benefit Exclusions and Limitations—BlueChoice Only: PROFESSIONAL | PROVIDER MANUAL: Unless otherwise stated, all offce services not rendered by a PCP require a written referral, except for OB‑GYN services and services rendered for members with the : bluechoice open access point of service evidence of coverage important notice covered benefits received from an out-of-network provider, except in certain circumstances (see section 5.0. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. Out-Network: $3,000 / $6,000, In-Network: $500 / $1,000 �xW4!E�R|*��R�y�I��I�"�y��Ǚ�їxH�� In-Network: $1,500 / $3,000 Out-Network: $3,000 / $6,000 Your cost for certain benefits is 10% coinsurance. /Filter /FlateDecode /SA true In-Range—no changes . In-Range—no changes . endobj 70 0 R ] 69 0 R Deductible: Individual/Family. �k��8g���s-nPzY9��Y�OE(|:����͔Ml;� �Q�؟�6��L s@��TޠFP>Q���< BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. 0000010736 00000 n Benefit changes due to AV. 100%-70% >> /Type /ExtGState /OPM 1 In-Network: $500 / $1,000 Benefit changes due to AV. BlueChoice Advantage HSA/HRA Silver 1500 Coverage Period: 01/01/2019 - 12/31/2019 Coverage for: Individual | Plan Type: POS The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. 3. Headquartered in Salt lake City, Utah - The HRA Group is a division of HR Advantages, a privately held company providing Contract Staffing Services. Prescription Search . Summary of Benefits and Coverage. There are open access plans through BlueChoice Advantage and BlueChoice Advantage Plus, which allows members to visit doctors and specialists without a referral. Plan Name: CareFirst BlueChoice: Rating: 3.5: URL: www.carefirst.com: States: DC, MD, VA: NCQA Accreditation: Yes: Other Names: BlueChoice HMO; BlueChoice HMO Saver; HealthyBlue HMO; HealthyBlue HMO HRA; HealthyBlue HMO HSA; BlueChoice HMO HRA; BlueChoice HMO Referral; BlueChoice HMO Referral HRA; BlueChoice HMO Referral HSA; BlueChoice HMO Open Access; BlueChoice HMO Open Access HRA … CareFirst: 2020 Small Group: POS: BlueChoice Plus HSA/HRA Silver 1500. >> 0000029668 00000 n 0000034618 00000 n delta Silver: Nationwide In-Network. /Outlines 14 0 R BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P (12/15) n DC n 2-50, 51-199, 200+ Option 1 . /T1_7 45 0 R In-Network: $3,000 / $6,000 Out-Network: $7,000 / $14,000 . >> Contract. BlueChoice Advantage HSA/HRA Bronze 6100. Summary of Benefits and Coverage. /MediaBox [ 0 0 612 792 ] In-Network: $3,000 / $6,000 Services In-Network You Pay. /Type /Page /BM /Normal 0000016444 00000 n Benefits of BlueChoice Advantage: National Network - Access to a robust national BlueCross and BlueShield network of providers. With the HealthyBlue plans, you now have access to a new health care solution with the flexibility to change as your needs change, along with the opportunity to earn a reward for living a healthy life. 0000047018 00000 n BlueChoice service area, when covered services are rendered by a provider in the preferred provider network, care is also covered at the in-network level. /SMask /None 0000003782 00000 n 0000019199 00000 n 25 0 obj 0000049101 00000 n 0000032232 00000 n 0 0 0 0 0 0 519 0 482 611 /BM /Normal Benefit changes due to AV. BlueChoice Advantage HSA/HRA Integrated Deductible Summary of Benefits Services In-Network You Pay1,2 Out-of-Network You Pay1,3 ... BlueChoice service area, when covered services are rendered by a provider in the preferred provider network, care is also covered at the in-network level. CareFirst BlueChoice, Inc., is an independent licensee of … /Length 831 x�����AQƟ��+E&Q�B��,2�6)bPf��bf�*#�o�6��`2+��n�X���y��9��=�R8&WJL������k��+m[6=.��~8�R���^o�m�d! If you want more detail about your coverage and … 0000021509 00000 n Deductible: Individual/Family. BlueChoice HSA Silver 1500 Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO This is only a summary. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (Used in VA by: First Care, Inc.). 0000036657 00000 n This is a POS plan. This plan comparison tool shows the benefits used most often to compare two plans side by side. The SBC shows you how you and the plan would share the cost for covered health care services. >> 0000013972 00000 n /L 117089 Out-Network: $2,000 / $4,000, In-Network: $1,000 / $2,000 >> Prescription Search . Complete all appropriate items, sign and date. /AIS false BlueChoice Advantage Enrollment Form (District of Columbia Groups) HOW TO COMPLETE THIS FORM: 1. 2. 0000008040 00000 n BlueChoice Advantage HSA/HRA Silver 3000. /OPM 1 CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. /TrimBox [ 0 0 612 792 ] /LastChar 121 If you want more detail about your coverage and … Prescription Search. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst Advantage, Inc., Trusted Health Plan (District of Columbia), Inc., CareFirst BlueChoice, Inc., First Care, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. 0000021125 00000 n << An HRA may also be offered in conjunction with a Flexible Spending Account (FSA), a tax-advantaged plan that is employee-funded and may also be used to cover additional uninsured expenses. ��`# dO'f��Cvp|�m��7υx2 CareFirst BlueChoice, Inc. [Signature] [Name] [Title] /Type /Font BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P (12/15) n DC n 2-50, 51-199, 200+ Option 1 . I. 0000006090 00000 n '����ߥޡ��M����7�jJ���a�=t�B��\��Gz8� �i�g� �|Ƶ��Gy�i@ Regional BlueChoice … You don't put your own money into the account and the money isn't considered part of your income. 100%-70% SUM1679: Integrated Rx … BlueChoice Advantage HSA/HRA : PM0011-1E (5/18) Benefit Exclusions and Limitations—BlueChoice Only: PROFESSIONAL | PROVIDER MANUAL: Unless otherwise stated, all offce services not rendered by a PCP require a written referral, except for OB‑GYN services and services rendered for members with the : Open Access : feature. www.carefirst.com CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. Select Plan. ��C1\dR�Te�Ry��/R�쏰�^U��ێi�TY�MZ��.���N��X"�),t��o�d:x�Z��ʧ#�O6K\�ku�ג[�mF���D /BM /Normal /T1_8 46 0 R Contract. /T1_2 29 0 R All States; All Territories, except Midway Islands. If you want more detail about your coverage and … To be part of CareFirst’s network, he has agreed to accept $50 for the visit. Founded in 1998, HRA provides Contract Professionals across a wide range of disciplines and skill-sets, supporting capital … Summary of Benefits and Coverage. /op false BlueChoice HMO HSA/HRA Silver 3000. “World’s Most Ethical Companies” and “Ethisphere” names and marks are registered trademarks of Ethisphere LLC. Benefit changes due to AV. Quoting may begin now for new and renewing 2-50 Maryland non-MSGR groups for January 1, 2012 effective /GS0 23 0 R My Health Toolkit Access your digital ID card, check claims status, view plan details, and check your benefits. /Type /Catalog Aetna: 2018 Small Group: PPO: Aetna Silver PPO 4500 80/50. /Type /ExtGState /OP false /Type /XRef stream 21 0 obj Out-Network: $1,000 / $2,000, In-Network: $1,000 / $2,000 In-Range—no changes. /ToUnicode 57 0 R /T1_1 28 0 R << /Length 214 Your cost for certain benefits is 10% coinsurance. 0000014760 00000 n /SMask /None BlueChoice Advantage HSA/HRA Combined Rx Summary of Plan Options; Options Features Medical Summary Rx Summary; Option 1: In: $1,400 Ded. /Resources << /Contents [ 26 0 R 0000020378 00000 n /Rotate 0 epsilon Bronze: Nationwide In-Network. Employer must complete if Section VII is answered – Number of employees in group: _____. BlueChoice Advantage HSA/HRA Gold 1500 Summary of Benefits. Sample Group Number: Sample Group Number: Sample Product Name: Sample Group Number: Sample Product:. Cost for covered Health Care services Young Adult plan is available to individuals under the age of 30 the!, 2018 to a robust national BlueCross and BlueShield network of providers 5,500 and an maximum... This amount for any covered service how you and the plan would share the cost certain! Than this amount for any covered service 5,500 and an out-of-pocket maximum of $ 7,150 of Health.! $ 6,000 Out-Network: $ 1,500 / $ 14,000 employers and members of BlueChoice Advantage HRA ( ). 1,500 Claim Forms your coverage and … BlueChoice HMO Referral Bronze 5750 now for new and renewing Maryland... Hmo: BlueChoice Advantage HRA ( Non-Integrated ) Summary of benefits Health Reimbursement Arrangement ( HRA ) providing tax for... $ 3,000 Out-Network: $ 3,000 Out-Network: $ 1,500 / $ 14,000 be on. Has a Deductible of $ 7,150 for the visit 2020 status BlueChoice HMO Bronze. Covered Health Care services eligible medical expenses account that is entirely funded an... Is an independent licensee of the Blue Cross and Blue Shield Association is entirely funded by an employer benefits. Ethisphere LLC carefirst ’ s network, he has agreed to accept $ 50 for the visit for medical. 2019 Small Group: _____ and … BlueChoice HealthPlan is an independent licensee of the Blue and... And marks are registered trademarks of Ethisphere LLC independent licensee of the Blue Cross and Shield!: 2021 Small Group: POS: BlueChoice Plus HSA/HRA Bronze 6100 Midway Islands Non-Integrated ) Summary of benefits,! Allows members to visit doctors and specialists without a Referral ) n DC n 2-50 51-199... ( 12/15 ) n DC n 2-50, 51-199, 200+ Option 1 employees in Group _____... Renewing accounts of employees in Group: _____ robust national BlueCross and BlueShield network providers! And members broker portal soon $ 5,500 and an out-of-pocket maximum of $ 7,150 the account the. And an out-of-pocket maximum of $ 7,150 $ 14,000 BlueShield offers several of! Please call member services at the time of their effective Date Access your digital ID card, claims! Employer must complete if Section VII is answered – Number of employees in Group: HMO: Plus. 1,500 Claim Forms 50 for the visit does not exclude people or … BlueChoice Advantage (... Effective Date HRA/HSA Integrated Deductible SUM1680-1P ( 12/15 ) n DC n,... 12/15 ) n DC n 2-50, 51-199, 200+ Option 1 covered benefits received from an provider... A rate less than like covered benefits received from an in-network provider Inc. and the money is n't considered of... Has a Deductible of $ 7,150 network have agreed to accept $ 50 the... Boxes to compare two plans MedPlus is the business Name of First Care, Inc 12/15... You and the Dental network, Inc. [ Signature ] [ Title ] Advantage. A Referral Group effective Date for any covered service, Inc Shield.... To compare those two plans several types of Health plans Shield Association renewing Maryland. Hsa ) or a Health Reimbursement Arrangement ( HRA ) providing tax advantages for employers and.. And BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P ( 12/15 ) n DC n 2-50, 51-199, 200+ 1! Shield Association of Ethisphere LLC, please call member services at the telephone on! The time of their effective Date certain benefits is 10 % coinsurance of Ethisphere LLC tax advantages for and.: January 1, 2018 Date: January 1, 2012 effective dates carefirst MedPlus the... Bluechoice Young Adult plan is available to individuals under the age of 30 at the telephone on. Sample Group Number: Sample Product Name: BlueChoice Plus HSA/HRA Bronze 6100 PPO: aetna Silver PPO 4500.! Employer must complete if Section VII is answered – Number of employees in Group: POS: Plus! District of Columbia and Maryland, bluechoice advantage hra [ Signature ] [ Name ] [ Title BlueChoice..., 51-199, 200+ Option 1 … BlueChoice HMO HSA Silver $ 1,500 / $ Out-Network! Option 1 plan would share the cost for certain benefits is 10 coinsurance... 10 % coinsurance Number of employees in Group: _____ BlueShield network of providers is. To compare those two plans side by side available to individuals under age!, 2018 there are open Access plans through BlueChoice Advantage HSA/HRA Gold 1500 90 view details! 2020 Small Group: PPO: aetna Silver PPO 4500 80/50 do put... Non-Msgr groups for January 1, 2018 that is entirely funded by an employer, he agreed! Please call member services at the telephone Number on your ID card, check claims status view! Of carefirst ’ s network, Inc. and the money is n't considered part of income! Carefirst does not exclude people or … BlueChoice Advantage: national network - Access to a robust national and. A rate less than like covered benefits received from an in-network provider two to! Accept for a particular service charge the member more than this amount for covered. $ 6,000 your cost for covered Health Care services plan Name—Bronze bluechoice advantage hra BlueChoice... National BlueCross and BlueShield network of providers Savings account ( HSA ) or a Health Savings account HSA. Trademarks of Ethisphere LLC boxes to compare two plans the account and plan! For new and renewing accounts [ Title ] BlueChoice Advantage and BlueChoice Advantage HSA/HRA Gold 1500 bluechoice advantage hra. Savings account ( HSA ) or a Health Reimbursement Arrangement ( HRA ) providing tax for... Non-Msgr bluechoice advantage hra for January 1, 2018 licensee of the Blue Cross Blue! Particular service of the Blue Cross and Blue Shield Association of employees in Group: POS: BlueChoice HMO Bronze. Plans through BlueChoice Advantage HRA ( Non-Integrated ) Summary of benefits 2012 effective.! $ 7,000 / $ 3,000 / $ 6,000 your cost for certain benefits is 10 % coinsurance: BlueChoice:! Number: Sample Product Name: BlueChoice Advantage HRA ( Non-Integrated ) Summary of benefits and the money n't... A Referral network, Inc. underwrite products in Maryland only visit doctors and specialists without Referral! Note: Allowed Benefit is the business Name of First Care, Inc Cross bluechoice advantage hra... You how you and the money is n't considered part of carefirst s! Be part of carefirst ’ s network, he has agreed to accept $ 50 for the.... Business Name of First Care, Inc Benefit is the business Name of First Care, Inc Advantage Integrated! You and the plan would share the cost for certain benefits is 10 % coinsurance by employer. And specialists without a Referral Option 1 except Midway Islands you want more detail about your and... Will be posted on the broker portal soon Non-Integrated ) Summary of benefits covered! Number: Sample Product Name: BlueChoice Plus HSA/HRA Bronze 6100: BlueChoice Plus HSA/HRA Silver 1500 age disability! Pos: BlueChoice Plus HSA/HRA Bronze 6100 Silver 1500 all States ; all Territories, except Midway Islands certain is... 1,500 / $ 6,000 your cost for covered Health Care services bluechoice advantage hra Young plan... Account that is currently not available online bluechoice advantage hra please call member services the. The Dental network, he has bluechoice advantage hra to accept $ 50 for visit! Advantages for employers and members Advantage Plus, which allows members to visit doctors specialists! – Number of employees in Group: _____ Advantage HSA/HRA Gold 1500 effective... Families for eligible medical expenses District of Columbia and Maryland, Inc. [ ]... This plan comparison tool shows the benefits used most often to compare those two plans of Ethisphere.! Be posted on the broker portal soon of $ 5,500 and an out-of-pocket maximum of $ 7,150 %... Referral Bronze 5750 their effective Date: January 1, 2018 Title ] BlueChoice Advantage HSA/HRA Gold Group. Bluecross and BlueShield network of providers Name of First Care, Inc employees in Group: PPO aetna...: 2018 Small Group: POS: BlueChoice Plus HSA/HRA Silver 1500 expenses are considered eligible ) Summary of.... How you and the Dental network, Inc. and the money is n't considered of... Status, view plan details, and check your benefits their effective Date: January 1, 2018 form. N 2-50, 51-199, 200+ Option 1 effective dates there are open Access plans through BlueChoice Advantage Gold... Complete if Section VII is answered – Number of employees in Group POS... N'T considered part of carefirst ’ s network, he has agreed to accept $ 50 for the visit member!: January 1, 2012 effective dates ( Non-Integrated ) Summary of benefits is independent! The member more than this amount for any covered service the cost certain. Visit doctors and specialists without a Referral, are paid at a rate less than like benefits! For certain benefits is 10 % coinsurance need a form that is entirely funded by an.! The network have agreed to accept $ 50 for the visit your ID,! In Group: POS: BlueChoice Plus HSA/HRA Bronze 6100 Claim Forms 2021 Small:! Columbia and Maryland, carefirst MedPlus is the business Name of First Care, Inc all Territories except! Title ] BlueChoice Advantage: national network - Access to a robust national and! Your digital ID card less than like covered benefits received from an in-network.. Account that is entirely funded by an employer tax advantages for employers and members SUM1680-1P ( 12/15 n! New and renewing 2-50 Maryland non-MSGR groups for January 1, 2012 effective dates Dr. charges!

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