1. Healthcare

Consumer Health Insurance
Plans 2015
For people who buy
their own insurance
MARYLAND
Welcome
Thank you for considering CareFirst BlueCross BlueShield and
CareFirst BlueChoice, Inc. (CareFirst) for your health care coverage.
Having provided coverage, information and support for more than
75 years, we know how much you and your family depend on your
health insurance provider. It’s a responsibility we take very seriously,
as we have with your grandparents, parents, friends and neighbors.
To help you better understand the plans, we’ve started this booklet
with a quick overview of some terms you should understand, some of
the highlights of health care reform and how to get the most out of
your new plan.
CareFirst—there for you then, here for you now.
We’re proud to be a locally-based affiliate of the Blue Cross and
Blue Shield Association, the nation’s oldest and largest family of
independent health benefits companies. Four generations have
entrusted us with their family’s health care coverage. Deciding to do
likewise would put you in good company; company that includes the
one in three Americans who have chosen BlueCross BlueShield.
If you have questions as you read through this booklet, you’ll find
answers online at www.carefirst.com/individual or give us a call at
800-544-8703, seven days a week, 8 a.m. – 8 p.m. You can use the
same number for our bilingual services, too.
Sincerely,
Vickie S. Cosby
Vice President, Consumer Direct Sales
Ready to
go shopping?
You can also visit us online at
www.carefirst.com/individual
to research and compare plans.
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What’s Inside…
Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Get to know the basics
Four things you need to know about health care reform . . . . . . . . 3
Health insurance basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Ways to save . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Choosing your CareFirst health care plan
The very big benefits of a very little card . . . . . . . . . . . . . . . . . . . 11
There’s even more to every CareFirst plan . . . . . . . . . . . . . . . . . . 16
Calculating your total monthly premium . . . . . . . . . . . . . . . . . . . . 19
Enroll today
Four ways to enroll in your new CareFirst plan . . . . . . . . . . . . . . . 29
More to smile about . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Additional information
Our commitment to you . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Not all services and procedures are covered by your benefits contract. This plan summary is for comparison
purposes only and does not create rights not given through the benefit plan.
Get to know the basics
Four things you need to know
about health care reform
If you buy your own health
insurance, understanding
these facts about the
Affordable Care Act (ACA)
will help as you choose
You must buy health insurance.
your new CareFirst health
Pure and simple, it’s the law. If you don’t have health
insurance, you’ll pay a tax penalty of $325 or 2 percent of
income for each family member, whichever is greater.
insurance plan.
All plans must cover the same
core benefits.
Every plan you’re about to review covers
these services:
■■ Office visits
You might qualify for financial
help from the government.
■■ Prescription drugs
To help make health insurance more
affordable, the federal government
offers two forms of financial assistance,
called subsidies. You may qualify if your
projected 2015 household income is:
■■ Hospitalization
■■ less than $46,680 for an individual
■■ less than $62,920 for a family of 2
■■ less than $79,160 for a family of 3
■■ less than $95,400 for a family of 4
■■ Preventive care
■■ Emergency services
■■ Lab tests, blood work, X-rays
■■ Immunizations
■■ Maternity and newborn care
■■ Mental health care
■■ Substance abuse services
■■ Pediatric dental and vision services
■■ less than $111,640 for a family of 5
Qualifying income levels change slightly
each year. Find detailed information on
www.carefirst.com/healthreform.
You can’t be denied coverage.
Even if you’re sick or have a pre-existing
condition, you can’t be charged more or
denied coverage.
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Health insurance basics
The more comfortable you get with the terms used to describe how health insurance works, the better
decisions you’ll make. Here’s a quick look at the most important ones.
Plans and providers
Provider network—CareFirst has a large group
or “network” of providers—doctors, hospitals and
pharmacies—you receive benefits and services from.
Primary Care Provider (PCP)—Your primary care
provider is your health care partner. They know and
understand you and your health care needs.
Patient-Centered Medical Home (PCMH)—A program
designed to give your primary care provider a more
complete view of all of your health needs, as well as the
care you receive from other providers. When you select
a primary care provider who participates in the PCMH
program, you are the center of an entire health care
team whose goal is to better manage and coordinate
your care and improve your health.
Plan types—Health Maintenance Organization
(HMO), Point of Service (POS) and Preferred
Provider Organization (PPO) refer to how your plan
provides coverage and which network of providers you
receive care from. The differences have to do with how
much flexibility you have when choosing providers,
balanced with how much of that provider’s costs you
will have to pay.
■■ Flexible—CareFirst’s BlueChoice HMO plans offer
the flexibility to see any of the 35,000 participating
providers in the CareFirst BlueChoice network.*
If you go outside of the network, only emergency
services are covered.
■■ More flexible—CareFirst BlueChoice’s POS plans
offer you more flexibility with coverage for both
in-network (CareFirst BlueChoice HMO network) and
out-of-network (CareFirst PPO network) providers.*
Receiving care in-network can save you money;
otherwise the out-of-network cost will apply. If your
provider does not participate in any of our networks,
you will have the greatest out-of-pocket costs.
■■ Most flexible—CareFirst’s PPO plans offer you the
most flexibility with coverage for both in and outof-network providers.* Choose from a network of
more than 40,000 local providers and thousands
nationally. Going out-of-network is an option, but will
cost you the most.
Our plans offer coverage when you are out of town:
■■ When you pick an HMO plan, you have access
to routine and urgent care when you’re away
for more than 90 consecutive days in any of our
participating states.
■■ When you pick a POS or PPO plan, you are
covered nationally with the BlueCard® network.
* Coverage is not available for services provided outside the United States,
except for emergency services.
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Financial terms
Premium—the money you pay each month for your
plan, or policy, based on where you live, number
and age of covered family members and the plan
you choose.
Cost-sharing—the part of your health care costs that
your plan doesn’t pay is your share. There are three
types of cost sharing:
■■ Deductible—the amount of money you must
Allowed benefit—the fee that providers in the
CareFirst and CareFirst BlueChoice network have
agreed to accept for a particular service. Example: Dr.
Smith charges $100 to see a patient. To be included
in a CareFirst or a CareFirst BlueChoice network, he
has agreed to accept $50 for the visit. After the patient
pays their copay or deductible, CareFirst will pay what’s
left of the $50 charge. A provider cannot charge a
member more than the alllowed benefit (in this case
$50) for any covered service.
pay each year before your plan begins paying
its portion. Your deductible will start over
every January 1.
■■ Copayment (copay)—a fixed-dollar
amount you pay when you visit a doctor or
other provider.
■■ Coinsurance—the percentage of the
allowed benefit you pay after you meet
your deductible.
Maximum out-of-pocket—the most you will have
to pay for medical expenses and prescriptions in a
calendar year. Your maximum out-of-pocket will start
over every January 1.
How much will I pay for medical services?
For example, say you have a BlueChoice HSA Silver $1,300 plan for an individual…here’s a quick look at
how much you will pay before your benefits kick in. Note your monthly premium does not count toward your
deductible or maximum out-of-pocket.
$
Until you
have spent
$1,300…
$
(your deductible)
YOU PAY
YOU PAY
You’ll pay 100% of
the allowed benefit—
the discounted rate you
receive for b
eing a
CareFirst member— for all covered services
When you
have spent
$6,350…
(your maximum
out-of-pocket)
CAREFIRST PAYS
Then you’ll pay just
a $30 copay for
some services and
20% coinsurance
$
CAREFIRST PAYS
You will pay nothing
for the remainder of
the year! C
areFirst will
pay 100% of your covered medical
expenses All in-network preventive services are available
before you meet your deductible. See page 14 for
a quick comparison of deductibles and maximum
out-of-pocket amounts for all CareFirst plans.
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Ways to save
We’ve been helping our members find ways to make health insurance more affordable for more than
75 years. It’s a commitment that still drives us today. And now the federal government has introduced
ways to help, too.
Lower health care costs with
financial assistance
One very important aspect of health care reform is the financial
assistance the federal government provides to lower monthly
premiums and limit out-of-pocket expenses for people who qualify.
They’re called subsidies, and are explained in a little more detail
below. If you qualify for a subsidy, you can still purchase a CareFirst
plan; however, you are required to buy your plan through the
Maryland Health Connection.
Help paying your monthly premiums
The Advanced Premium Tax Credit helps reduce your monthly
premium so you pay less for your health plan each month. Once
you apply, your tax credit will be sent to CareFirst and applied to
your bill, reducing or even eliminating your premium (excludes the
BlueChoice Young Adult plan).
Help lowering your out-of-pocket expenses
Check out our subsidy estimator
at www.carefirst.com/individual
to see if you qualify for financial
assistance.
The Cost-sharing Reduction Subsidy helps to limit how much you
spend out-of-pocket on expenses like copays, coinsurance and
deductibles. By lowering your maximum, your health plan begins
paying 100 percent of your costs sooner than it would have without
the subsidy. Cost-sharing subsidies are only for Silver level plans
bought on the Maryland Health Connection.
Take a moment to see if you qualify
If you qualified for a subsidy in 2014, you need to contact the
Maryland Health Connection and be re-evaluated for financial
assistance for 2015 during open enrollment, Nov. 15 – Feb. 15. (If
you want your 2015 subsidy to begin January 1, you must complete
the eligibility process by December 18). For more details, visit
www.marylandhealthconnection.gov.
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Earn $150–$400* from our
Blue Rewards program
Blue Rewards is an incentive program where you can earn $150 per adult
and up to $400 per family for taking an active role in getting healthy
and staying healthy. It’s a financial reward you can apply to your monthly
premium payment, deductible, copays or coinsurance. Earn your Blue
Reward in just four steps:
1. Select a primary care provider (PCP) who participates in our PatientCentered Medical Home program (PCMH), a program that provides
your doctor with a more complete view of your health needs (ages 2+)
2. Agree to receive wellness-related communications from us
electronically—information delivered when and where you need it
(ages 18+)
3. Complete an online health assessment, a great starting point in
charting your healthier future! (ages 18+)
4. Visit your selected PCMH PCP and complete your Health and
Wellness Evaluation Form, another important part of mapping out
your plan (ages 2+)
*The reward is in the form of a Blue Rewards incentive card. If you have a Health Savings Account
(HSA) plan, you must meet the IRS minimum deductible for an HSA plan ($1,300 for individual
coverage/$2,600 for family coverage) before you can use your reward for medical expenses.
Cut your prescription costs
If prescriptions are a significant part of your out-of-pocket costs,
here are some ways you may be able to reduce what you
spend on them.
Think generic
They cost less than, but work the same as, brand drugs. Ask your doctor to
prescribe generic drugs and choose generics every time they’re available
to save the most.
Use your mailbox
By using the Mail Service Pharmacy program you can save the most
money on your maintenance medications and have them delivered to your
home. It’s fast, accurate and will save you money.
Order in bulk
Get up to a three-month supply of maintenance medications for the cost
of two copays at retail stores or through the mail. If your plan requires
coinsurance, the cost is the same regardless of the quantity ordered.
However, mail order offers lower prices.
See more complete information about prescriptions on page 18.
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Save your money
An HSA is a health savings
account and having one can
save you a lot of money when
you enroll in one of our highdeductible health plans, which
have higher deductibles and
lower premiums. You don’t have
to pay taxes on money you
put into an HSA to cover your
health care expenses. Partner
with a financial institution of
your choice and contribute
tax-deductible money into
your health savings account.
The funds roll over from year
to year, so HSAs are great
for saving up in case of a
medical emergency or a big
health expense.
Your HSA
contribution
is tax free…
1. Pre-tax contribution
2. Tax-free withdrawals
for eligible expenses
3. Tax-free growth
When you need care
Being familiar with how your plan provides coverage can add
up to big savings over the course of the year. For example,
there’s a big difference between needing prompt medical attention and
having a life-or-death situation. There’s a financial difference too: if your
life isn’t in danger, you’ll spend less out-of-pocket by going to a local
convenience care or urgent care center. Keep in mind:
■■ Get lab work done in your plan’s network.
■■ Have outpatient surgery done at a freestanding surgery center, not
a hospital.
■■ Don’t schedule doctor’s visits at the hospital—you’ll often get charged
by the doctor AND by the hospital.
■■ Use a convenience care or urgent care center for non-life threatening
emergencies.
Symptom
Stitches
Mild asthma
Sprain, strain
Nausea, vomit, diarrhea
Cough, sore throat
Ear or sinus pain
Convenience care
centers—also known as
retail health clinics, tend to
be located inside a pharmacy
or retail store and offer easy
access to treatment for nonemergency care such as colds,
pink eye, strep tests and
vaccinations. Convenience
care centers offer extended
weekend hours and can see
you quickly.
Doctors’ Office
Setting
Convenience Care/
Urgent Care Center
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Emergency
Room
Sudden or unexplained loss of
consciousness
Signs of a heart attack, such as sudden/
severe chest pain or pressure
Sign of stroke, such as numbness of the
face, arm or leg on one side of the body;
difficulty talking; sudden loss of vision
High fever with stiff neck, mental
confusion and/or difficulty breathing
✔
✔
✔
✔
✔
✔
Coughing up or vomiting blood
Suicidal feelings
For illustrative purposes only. This information is not intended as medical advice.
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Choosing your CareFirst
health care plan
The very big benefits
of a very little card
A CareFirst membership card is actually quite
powerful. It comes with every CareFirst plan, but
so do all of these benefits.
■■
The Blue Rewards program—earn $150
(families get up to $400) by completing
four steps
■■
$0 benefits—pay nothing when you use
one of our in-network providers for:
adult physicals
well-child exams and immunizations
OB/GYN visits and pap tests
mammograms
prostate and colorectal screenings
routine pre-natal maternity services
■■
One of the largest doctor and hospital
networks in the region
■■
60,000+ pharmacies nationwide
and convenient mail order services
■■
No referrals to see specialists
■■
Vision care—get one $0 eye exam each year
plus discounts* on contact lenses, laser vision
correction surgery and glasses when you use
a provider within our vision network
■■
Comprehensive dental and vision coverage
for kids under 19
■■
National coverage available either through
the BlueCard® PPO network or with Away
From Home Care™—limitations may apply
■■
My Account mobile app—account
information in the palm of your hand
* Discount is subject to provider participation
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Blue365
Discount program
Save money with exclusive health and wellness deals from top national
and local retailers on fitness gear, gym memberships, weight loss
programs, cell phone plans, hotels, resorts and more. For the latest
deals, visit www.carefirst.com/wellnessdiscounts
First Help
™
24/7 access to a registered nurse
Ask a registered nurse any question, any time. Just call 800-535-9700 and
a registered nurse will ask about your symptoms and help you decide on
the best source of care.
We’re committed to helping
you achieve a healthy lifestyle,
so we offer a Health and
Wellness package with every
health plan. Here are some of
the exclusive discounts and
free tools you can look
forward to.
Health Coaching
Personalized telephone coaching service
Learn new and positive lifestyle behaviors with a personalized health plan
focused on helping you achieve your health goals. You’ll be able to get
one-on-one attention through phone calls or through a secure, private
web-based message board.
CareFirst Mobile
Account info wherever you go
Put the account information you need in the palm of your hand. Manage
your care, find a doctor or urgent care center, always have access to your
ID card and more when you download the My Account mobile app.
Ready, Step, Go!
Pedometer app
Count your steps, distance traveled and calories burned for each workout
with the free CareFirst Ready, Step, Go! app. The app is available for
iPhone™, iPod Touch™ or Android™ smartphones—visit your app store and
search for Ready, Step, Go!
Health and wellness information is always at your fingertips
■■ Visit the My Care First website and access 300+ interactive health tools, 400+ podcasts, dozens
of recipes, videos and tutorials on chronic diseases and an encyclopedia with info on more than
3,000 conditions: www.carefirst.com/mycarefirst
■■ Vitality magazine gives you tips for living a healthier lifestyle with articles about nutrition,
preventive health, physical fitness and more: www.carefirst.com/vitality
■■ Sign up for a customized CareFirst e-newsletter and every month we’ll send you articles and
recipes personalized to your areas of interest: www.carefirst.com/healthnews
■■ Like us on Facebook and get daily posts that help support your personal health goals and keep
you healthier: www.facebook.com/carefirst
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Understanding metal levels
CareFirst’s plans within each metal level give you choices of provider networks, different cost-sharing arrangements
and premiums. People under the age of 30 also have the choice of buying a Catastrophic plan, which is similar to a
Bronze plan. The chart below shows how each type of plan relates to the annual premiums* and individual annual
deductibles—as monthly premiums go up, annual deductibles go down.
CATASTROPHIC
BRONZE
SILVER
GOLD
PLATINUM
Lowest premiums
for individuals
under 30
Bronze level of
coverage pays
60 percent of
health care costs.
Silver level of
coverage pays
70 percent of
health care costs.
Gold level of
coverage pays
80 percent of
health care costs.
Platinum level of
coverage pays
90 percent of
health care costs.
$709
$546
$430
$406
$315
$246
$112
Age
26
$145
Age
26
$181
Age
40
Age
55
$197
Age
26
Age
40
Age
55
Age
26
$6,600
Deductible
“I’m young, healthy
and I’m looking
for the plan
with the lowest
monthly premium.”
“I don’t want to
Age
40
Age
55
Age
26
$0–$1,500
Deductible
$1,300–$2,500
Deductible
$3,500–$6,000
Deductible
$326
$313
$251
“I’m looking for
“I may be eligible
good coverage
for both forms
with low out-of-
of financial
pocket costs and
assistance.”
deductibles.”
Age
40
Age
55
$0 Deductible
“I want the best
coverage. I don’t
mind paying higher
premiums to get
the lowest out-ofpocket costs.”
pay a lot of money
each month…even if
that means a higher
deductible.”
* Rates are based on the average for each plan per metal level and all four geographical regions for the age indicated.
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Narrowing down your selection
This chart shows the features people use most often to compare plans. Use it to find your top choices—based on
plan type or deductible, or specific features like the option to add an HSA account, or out-of-network coverage,
coinsurance level…whatever’s most important to you.
CATASTROPHIC
BRONZE LEVEL PLANS
SILVER LEVEL PLANS
Plan Name
BlueChoice
Young Adult *
$6,600
BlueChoice
HSA Bronze
$6,000
BlueChoice
Plus Bronze
$5,500
BlueChoice
HSA Bronze
$4,000
BluePreferred
HSA Bronze
$3,500
BlueChoice
Plus Silver
$2,500
BlueChoice
Silver
$2,000
Plan Type
(page 5)
HMO
HMO
POS
HMO
PPO
POS
HMO
Deductible
$6,600
$6,000
$5,500
$4,000
$3,500
$2,500
$2,000
Individual
Maximum
Out-of-Pocket**
$6,600
$6,000
$6,350
$6,350
$6,350
$6,350
$6,350
Coinsurance
0%
0%
20%
30%
20%
20%
20%
Copays
(PCP/Specialist)
$0
$0
$35 / $45
$30 / $40
$30 / $40
$20 / $40
$30 / $40
✔
✔
Plan Features
Out-of-Network
Coverage
✔
No deductible for
primary care visits,
urgent care and
all generics
✔
✔
✔
No charge and
no deductible for
primary care visits,
labs, X-rays and
generic drugs
Tax-savings with an
HSA (page 8)
✔
✔
✔
Blue Rewards
program
(page 8)
✔
✔
✔
✔
✔
✔
✔
National coverage
available
(limitations
may apply)
✔
✔
✔
✔
✔
✔
✔
* Available to individuals under the age of 30. Also available to people who have received certification from an Exchange that they are exempt from the individual
mandate because they do not have an affordable coverage option or because they qualify for a hardship exemption. Visit your public Exchange for more details.
** Family deductible and maximum out-of-pocket is double the individual deductible and maximum out-of-pocket.
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Please refer to the fold-out comparison
chart for detailed benefit information.
SILVER LEVEL PLANS
GOLD LEVEL PLANS
PLATINUM LEVEL PLANS
BluePreferred
HSA Silver
$1,500
BlueChoice
HSA Silver
$1,300
HealthyBlue
Gold
$1,500
BlueChoice
Gold
$1,000
BluePreferred
Gold
$500
BlueChoice
Gold
$0
BluePreferred
Platinum
$0
HealthyBlue
Platinum
$0
PPO
HMO
POS
HMO
PPO
HMO
PPO
POS
$1,500
$1,300
$1,500
$1,000
$500
$0
$0
$0
$5,500
$6,350
$3,450
$3,750
$3,750
$6,350
$1,800
$2,000
30%
20%
0%
10%
20%
30%
10%
0%
$30 / $40
$30 / $40
$0 / $40
$20 / $30
$30 / $40
$20 / $30
$20 / $30
$0 / $30
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
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There’s even more to
every CareFirst plan
CareFirst health plans were designed to keep you healthy. That’s why we include vision, prescription drug
and pediatric dental coverage for all of our members. Because your health is important.
Vision
Every CareFirst health plan includes basic eye-care
benefits for everyone covered by your plan. These
important benefits are offered to you through Davis
Vision*, the administrator for the products, services and
discounts described below.
Children (up to age 19)
■■ One no-charge in-network routine exam
per calendar year
■■ Up to $40 reimbursement per calendar year for
out-of-network exams
■■ No copay for frames and basic lenses for glasses,
or contact lenses in Davis Vision collection
(in-network)
■■ Up to $40 reimbursement for single-vision
lenses and up to $70 for frames from an
out-of-network provider
For a routine eye exam, just call and make an
appointment with one of our many providers.
Remember, both the pediatric and adult vision benefits
are included in your plan’s monthly premium.
Adults (19 and over)
■■ One no-charge in-network routine exam1
per calendar year
■■ Up to $40 reimbursement per calendar year for
out-of-network exams
■■ Discounts2 of approximately 30 percent on:
eyeglass lenses, frames and contacts
laser vision correction
scratch-resistant lens coating and
progressive lenses
■■ No claims to file when you see a Davis
Vision provider
Exam only subject to deductible in BlueChoice Young Adult plan.
A s of April 1, 2014, some providers in Maryland may no longer provide
these discounts.
*Davis Vision is an independent company.
1
2
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To locate a provider, call Davis
Vision at 800-783-5602 or visit
www.carefirst.com/doctor.
Children’s dental
(up to age 19)
Did you know that comprehensive dental care can help detect other health
problems before they become more serious? Did you know that the health
of our teeth has a major impact on digestion, growth rate and many other
aspects that affect overall health? We did! That’s why all CareFirst plans
provide kids under 19 with dental benefits at no extra charge.
Pediatric dental (included)
In-Network
Out-of-Network
Member Pays
Individual Cost Per Day
Deductible
Network
Preventive & Diagnostic Services (Class
I) Exams (2 per year), cleanings (2 per
year), fluoride treatments (2 per year),
sealants, bitewing X-rays (2 per year),
full mouth X-ray (one every 3 years)
Basic Services (Class II) Fillings
(amalgam or composite), simple
extractions, non-surgical periodontics
Major Services – Surgical (Class III)
Surgical periodontics, endodontics,
oral surgery
Major Services – Restorative (Class IV)
Crowns, dentures, inlays and onlays
Orthodontic Services** (Class V)
when medically necessary
Included in your medical plan premium-no additional monthly charge
$25 Individual per calendar year
(Applies to Classes II, III & IV)
$50 Individual per calendar year
(Applies to Classes II, III & IV)
Over 3,600 providers in MD, DC,
and northern VA.
63,000 dentists nationally.
Over 4,200 providers in
MD, DC, and northern VA.
95,000 dentists nationally.
No charge
20% of Allowed Benefit*
(no deductible)
20% of Allowed Benefit*
after deductible
40% of Allowed Benefit*
after deductible
50% of Allowed Benefit*
after deductible
65% of Allowed Benefit*
after deductible
50% of Allowed Benefit* no
deductible**
65% of Allowed Benefit* no
deductible**
Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes only and does not create
rights not given through the benefit plan.
*CareFirst payments are based on the CareFirst Allowed Benefit. Participating dentists accept 100% of the CareFirst Allowed Benefits as payment
in full for covered services. Non-participating dentists may bill the member for any amount over the Allowed Benefit. Providers are not required to
accept CareFirst’s Allowed Benefits on non-covered services. This means you may have to pay your dentist’s entire billed amount for these noncovered services. At your dentist’s discretion, they may choose to accept the CareFirst Allowed Benefit, but are not required to do so. Please talk
with your dentist about your cost for any dental services.
**Orthodontic services are subject to the deductible for the BlueChoice Young Adult $6,600 plan only.
CareFirst offers four dental plans for family members age 19 and older.
With affordable premiums, a large network and a range of deductibles and cost-sharing,
CareFirst has a dental plan that’s right for you. See pages 41 and 42 for details.
Consumer Health Insurance Plans 2015
■
Maryland
17
Prescription drug coverage
All CareFirst plans include prescription drug coverage, so you can get the
medications you need. Here’s how the program works:
■■ Depending on your plan, you’ll either have to meet your plan’s deductible
before prescription coverage begins (because it’s integrated with your
other medical expenses) or you’ll have a separate, lower deductible just
for drugs, which gives you drug coverage much sooner.
■■ With each drug purchase, you’ll likely pay coinsurance or a copay.
■■ All drug charges count toward your plan’s in-network maximum
out-of-pocket.
■■ There are four tiers of drugs. Generally, generics cost the least and
specialty drugs cost the most:
1. Generic drugs work the same as brand-name drugs, but cost
much less.
2. Preferred brand drugs are brand-name medications that aren’t
available yet in generic form, but are chosen for their effectiveness
and affordability compared to alternatives. Note: if a generic drug
becomes available, the preferred brand drug will be moved to the
non-preferred brand category and will cost more money.
Savings tip!
Always ask your provider
to prescribe a generic
drug. If you are currently
taking a preferred brand or
non-preferred brand drug, it’s
important to regularly check
with your pharmacy to see if a
generic version is available.
3. Non-preferred brand drugs are often available in less
expensive forms, either as generics or preferred brand drugs.
You will pay more for this category of drugs.
Note: if your provider prescribes a non-preferred brand drug and
you get a non-preferred brand drug when a generic is available,
you will pay the non-preferred brand copay or coinsurance plus the
difference between the generic and non-preferred brand drug cost
up to the cost of the prescription.
4. Specialty drugs are often high-cost prescription drugs that may
require special handling, administration or monitoring and may
be oral or injectable medications used to treat serious or chronic
medical conditions.
■■ Preventive drugs are also available at no cost to you. They will be
fully covered by your prescription drug plan as long as you meet the
eligibility requirements.
We’ve included an outline of prescription benefits in the fold-out chart
included with this book. Check-out line 38 in that chart for details.
Visit www.carefirst.com/acarx and see what tier
your drugs are covered under and to find the most
up-to-date list of preventive drugs.
18
Consumer Health Insurance Plans 2015
■
Maryland
Maryland
Calculating your total
monthly premium
Baltimore C
Age
BlueChoice
Young Adult
$6,350
BlueChoice
HSA Bronze
$6,000
Blu
Plus
$
0-20
21
22
23
24
25
Figuring out the total monthly premium for the plans
you’re
26
considering is actually pretty simple. Here are the
three things you
27
28
need to do.
29
30
31
NA*
1.Find your county’s rate sheet on the following pages.32
NA*
NA* that
2.For each plan you’re considering, circle the amount in33that column
NA*
corresponds with your age when coverage will begin.34
35
NA*
3.If you’re buying an individual plan, that’s it! If it’s a family
repeat step
36 plan,NA*
two for each family member who will be covered by your
plan—just
37 new NA*
your three oldest kids under age 21. All are covered, 38
but only NA*
three count
39
NA*
toward your overall rate.
40
NA*
41
NA*
42
NA*
43
NA*
44
NA*
Need a “for instance?”
Howard
County
45
NA*
Michael and Samantha are married with 3 kids—Meredith, 15
46
NA*
Age
Robin, 17 and Nathan, 23. They live in Howard County and want to
47
NA*
BlueChoice
48
NA*
calculate their family’s monthly premium for the BlueChoice Plus
PlusNA*
Silver
49
Silver $2,500.
$2,500
50
NA*
0-20
x2
$125.38
Using their county’s rate chart, they find their plan’s column and
51
NA*
21
$197.44
52
NA*
find and circle:
22
$197.44
53
NA*
■■ Meredith and Robin’s rate in their age row (0-20)—
23
$197.44
54
NA*
24
$197.44
they make a note to add that rate twice, once for
55
NA*
25
$198.23
56
NA*
each daughter
26
$202.18
57
NA*
■■ Nathan’s rate in his age row (23)
58
NA*
47
$308.61
59
NA*
■■ Samantha’s rate in her age row (48)
48
$322.82
60
NA*
49
$336.84
61
NA*
■■ Michael’s rate in his age row (53)
50
$352.64
62
NA*
51
$368.23
63
NA*
They add it up and write it in at the top of the fold-out chart to use
52
$385.41
64
NA*
in making their final decision.
53
$402.79
65+**
NA*
$ 1,173.81 $
$
* If you are age 65 or older, you can only apply if y
** Also available to people who have received cer
coverage option or because they qualify for a h
Consumer Health Insurance Plans 2015
■
Maryland
19
Baltimore City; Anne Arundel, Baltimore, Harford and Howard Counties
Age
Bronze Level Plans
BlueChoice BlueChoice BlueChoice BlueChoice
Young Adult HSA Bronze Plus Bronze HSA Bronze
$6,600
$6,000
$5,500
$4,000
$72.07
$113.50
$113.50
$113.50
$113.50
$113.96
$116.23
$118.95
$123.38
$127.01
$128.83
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+**
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
$
$82.16
$129.39
$129.39
$129.39
$129.39
$129.91
$132.50
$135.60
$140.65
$144.79
$146.86
$149.96
$153.07
$155.01
$157.08
$158.12
$159.15
$160.19
$161.22
$163.29
$165.36
$168.47
$171.44
$175.58
$180.76
$186.84
$194.09
$202.24
$211.55
$220.74
$231.09
$241.31
$252.57
$263.96
$276.25
$288.54
$301.87
$315.33
$329.69
$336.81
$351.17
$363.59
$371.74
$381.96
$388.17
$388.17
$
$96.52
$152.01
$152.01
$152.01
$152.01
$152.61
$155.65
$159.30
$165.23
$170.09
$172.53
$176.17
$179.82
$182.10
$184.53
$185.75
$186.97
$188.18
$189.40
$191.83
$194.26
$197.91
$201.41
$206.27
$212.35
$219.50
$228.01
$237.58
$248.53
$259.32
$271.48
$283.49
$296.71
$310.09
$324.53
$338.97
$354.63
$370.44
$387.31
$395.67
$412.54
$427.13
$436.71
$448.72
$456.02
$456.02
Silver Level Plans
BluePreferred
HSA Bronze
$3,500
$85.82
$135.15
$135.15
$135.15
$135.15
$135.69
$138.39
$141.64
$146.91
$151.23
$153.39
$156.64
$159.88
$161.91
$164.07
$165.15
$166.23
$167.31
$168.39
$170.56
$172.72
$175.96
$179.07
$183.40
$188.80
$195.15
$202.72
$211.24
$220.97
$230.56
$241.37
$252.05
$263.81
$275.70
$288.54
$301.38
$315.30
$329.36
$344.36
$351.79
$366.79
$379.77
$388.28
$398.96
$405.44
$405.44
$
$
$109.61
$172.62
$172.62
$172.62
$172.62
$173.31
$176.76
$180.90
$187.64
$193.16
$195.92
$200.07
$204.21
$206.80
$209.56
$210.94
$212.32
$213.70
$215.08
$217.85
$220.61
$224.75
$228.72
$234.24
$241.15
$249.26
$258.93
$269.80
$282.23
$294.49
$308.30
$321.93
$336.95
$352.14
$368.54
$384.94
$402.72
$420.67
$439.83
$449.33
$468.49
$485.06
$495.93
$509.57
$517.86
$517.86
$
BlueChoice BlueChoice
Plus Silver
Silver
$2,500
$2,000
$125.38
$197.44
$197.44
$197.44
$197.44
$198.23
$202.18
$206.92
$214.62
$220.94
$224.10
$228.84
$233.58
$236.54
$239.70
$241.28
$242.86
$244.44
$246.02
$249.18
$252.33
$257.07
$261.61
$267.93
$275.83
$285.11
$296.17
$308.61
$322.82
$336.84
$352.64
$368.23
$385.41
$402.79
$421.54
$440.30
$460.64
$481.17
$503.09
$513.95
$535.87
$554.82
$567.26
$582.86
$592.33
$592.33
$
BluePreferred
HSA Silver
$1,500
BlueChoice
HSA Silver
$1,300
$136.03
$214.22
$214.22
$214.22
$214.22
$215.08
$219.36
$224.50
$232.86
$239.71
$243.14
$248.28
$253.42
$256.64
$260.06
$261.78
$263.49
$265.21
$266.92
$270.35
$273.77
$278.92
$283.84
$290.70
$299.27
$309.34
$321.33
$334.83
$350.25
$365.46
$382.60
$399.52
$418.16
$437.01
$457.36
$477.71
$499.78
$522.06
$545.84
$557.62
$581.40
$601.96
$615.46
$632.38
$642.66
$642.66
$121.27
$190.97
$190.97
$190.97
$190.97
$191.73
$195.55
$200.14
$207.59
$213.70
$216.75
$221.34
$225.92
$228.78
$231.84
$233.37
$234.89
$236.42
$237.95
$241.01
$244.06
$248.64
$253.04
$259.15
$266.79
$275.76
$286.46
$298.49
$312.24
$325.80
$341.07
$356.16
$372.78
$389.58
$407.72
$425.86
$445.53
$465.40
$486.59
$497.10
$518.29
$536.63
$548.66
$563.75
$572.91
$572.91
$127.47
$200.74
$200.74
$200.74
$200.74
$201.54
$205.56
$210.37
$218.20
$224.63
$227.84
$232.65
$237.47
$240.48
$243.70
$245.30
$246.91
$248.51
$250.12
$253.33
$256.54
$261.36
$265.98
$272.40
$280.43
$289.86
$301.11
$313.75
$328.21
$342.46
$358.52
$374.38
$391.84
$409.50
$428.57
$447.64
$468.32
$489.20
$511.48
$522.52
$544.80
$564.07
$576.72
$592.58
$602.21
$602.21
$
$
$
*Also available to people who have received certification from an Exchange that they are exempt from the individual mandate because they do not have an
affordable coverage option or because they qualify for a hardship exemption. Visit your public Exchange for more details.
** If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
20
Consumer Health Insurance Plans 2015
■
Maryland
Baltimore City; Anne Arundel, Baltimore, Harford and Howard Counties
Age
Gold Level Plans
Platinum Level Plans
HealthyBlue
Gold
$1,500
BlueChoice
Gold
$1,000
BluePreferred
Gold
$500
BlueChoice
Gold
$0
$168.15
$264.80
$264.80
$264.80
$264.80
$265.86
$271.16
$277.51
$287.84
$296.31
$300.55
$306.91
$313.26
$317.23
$321.47
$323.59
$325.71
$327.82
$329.94
$334.18
$338.42
$344.77
$350.86
$359.34
$369.93
$382.37
$397.20
$413.89
$432.95
$451.75
$472.94
$493.86
$516.89
$540.20
$565.35
$590.51
$617.78
$645.32
$674.71
$689.28
$718.67
$744.09
$760.78
$781.69
$794.41
$794.41
$147.62
$232.47
$232.47
$232.47
$232.47
$233.40
$238.05
$243.63
$252.70
$260.14
$263.86
$269.43
$275.01
$278.50
$282.22
$284.08
$285.94
$287.80
$289.66
$293.38
$297.10
$302.68
$308.03
$315.46
$324.76
$335.69
$348.71
$363.35
$380.09
$396.60
$415.19
$433.56
$453.78
$474.24
$496.33
$518.41
$542.36
$566.53
$592.34
$605.12
$630.93
$653.25
$667.89
$686.26
$697.42
$697.42
$180.46
$284.19
$284.19
$284.19
$284.19
$285.33
$291.01
$297.84
$308.92
$318.01
$322.56
$329.38
$336.20
$340.46
$345.01
$347.28
$349.56
$351.83
$354.11
$358.65
$363.20
$370.02
$376.56
$385.65
$397.02
$410.38
$426.29
$444.19
$464.66
$484.83
$507.57
$530.02
$554.75
$579.76
$606.75
$633.75
$663.02
$692.58
$724.13
$739.76
$771.30
$798.58
$816.49
$838.94
$852.58
$852.58
$152.92
$240.82
$240.82
$240.82
$240.82
$241.79
$246.60
$252.38
$261.78
$269.48
$273.34
$279.12
$284.90
$288.51
$292.36
$294.29
$296.21
$298.14
$300.07
$303.92
$307.77
$313.55
$319.09
$326.80
$336.43
$347.75
$361.24
$376.41
$393.75
$410.85
$430.11
$449.14
$470.09
$491.28
$514.16
$537.04
$561.84
$586.89
$613.62
$626.87
$653.60
$676.72
$691.89
$710.91
$722.47
$722.47
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+*
$
$
$
$
HealthyBlue BluePreferred
Platinum
Platinum
$0
$0
$200.77
$316.18
$316.18
$316.18
$316.18
$317.45
$323.77
$331.36
$343.69
$353.81
$358.86
$366.45
$374.04
$378.78
$383.84
$386.37
$388.90
$391.43
$393.96
$399.02
$404.08
$411.67
$418.94
$429.06
$441.70
$456.56
$474.27
$494.19
$516.96
$539.40
$564.70
$589.68
$617.18
$645.01
$675.05
$705.08
$737.65
$770.53
$805.63
$823.02
$858.11
$888.47
$908.39
$933.36
$948.54
$948.54
$
$220.39
$347.08
$347.08
$347.08
$347.08
$348.46
$355.41
$363.74
$377.27
$388.38
$393.93
$402.26
$410.59
$415.80
$421.35
$424.13
$426.90
$429.68
$432.46
$438.01
$443.56
$451.89
$459.88
$470.98
$484.87
$501.18
$520.61
$542.48
$567.47
$592.11
$619.88
$647.30
$677.49
$708.04
$741.01
$773.98
$809.73
$845.83
$884.35
$903.44
$941.97
$975.28
$997.15
$1,024.57
$1,041.23
$1,041.23
A plan just for yourself?
For each plan you’re
interested in:
1. Go down the plan column
to the row that matches
your age when coverage
will begin
2. Circle that premium
3. Repeat for all of the plans
you’re interested in
Family plan? Use the
same county rate table.
1. Find the age rows in
the plan column and
circle the rates for:
You
Your spouse
Your three oldest
kids under 21 (all are
covered, but only
three count toward
overall rate)
All kids 21-25
2. Add up everyone’s rate
3. Repeat for each plan
you want to consider
$
* If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
Consumer Health Insurance Plans 2015
■
Maryland
21
Allegany, Carroll, Frederick, Garrett and Washington Counties
Age
Bronze Level Plans
BlueChoice BlueChoice BlueChoice BlueChoice
Young Adult HSA Bronze Plus Bronze HSA Bronze
$6,600
$6,000
$5,500
$4,000
$66.37
$104.51
$104.51
$104.51
$104.51
$104.93
$107.02
$109.53
$113.61
$116.95
$118.62
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+**
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
$
$75.66
$119.14
$119.14
$119.14
$119.14
$119.62
$122.00
$124.86
$129.51
$133.32
$135.23
$138.09
$140.95
$142.73
$144.64
$145.59
$146.55
$147.50
$148.45
$150.36
$152.26
$155.12
$157.86
$161.68
$166.44
$172.04
$178.71
$186.22
$194.80
$203.26
$212.79
$222.20
$232.57
$243.05
$254.37
$265.69
$277.96
$290.35
$303.57
$310.13
$323.35
$334.79
$342.30
$351.71
$357.43
$357.43
$
$88.88
$139.97
$139.97
$139.97
$139.97
$140.52
$143.32
$146.68
$152.14
$156.62
$158.86
$162.22
$165.58
$167.68
$169.92
$171.04
$172.16
$173.28
$174.40
$176.64
$178.88
$182.23
$185.45
$189.93
$195.53
$202.11
$209.95
$218.77
$228.84
$238.78
$249.98
$261.03
$273.21
$285.53
$298.83
$312.12
$326.54
$341.09
$356.63
$364.33
$379.87
$393.30
$402.12
$413.18
$419.90
$419.90
Silver Level Plans
BluePreferred
HSA Bronze
$3,500
$79.02
$124.44
$124.44
$124.44
$124.44
$124.94
$127.43
$130.42
$135.27
$139.25
$141.24
$144.23
$147.22
$149.08
$151.07
$152.07
$153.07
$154.06
$155.06
$157.05
$159.04
$162.03
$164.89
$168.87
$173.85
$179.70
$186.66
$194.50
$203.46
$212.30
$222.26
$232.09
$242.91
$253.86
$265.69
$277.51
$290.33
$303.27
$317.08
$323.93
$337.74
$349.69
$357.53
$367.36
$373.33
$373.33
$
$
$100.93
$158.95
$158.95
$158.95
$158.95
$159.58
$162.76
$166.58
$172.77
$177.86
$180.40
$184.22
$188.03
$190.42
$192.96
$194.23
$195.50
$196.78
$198.05
$200.59
$203.13
$206.95
$210.60
$215.69
$222.05
$229.52
$238.42
$248.43
$259.88
$271.16
$283.88
$296.43
$310.26
$324.25
$339.35
$354.45
$370.82
$387.35
$405.00
$413.74
$431.38
$446.64
$456.65
$469.21
$476.84
$476.84
$
BlueChoice BlueChoice
Plus Silver
Silver
$2,500
$2,000
$115.45
$181.81
$181.81
$181.81
$181.81
$182.53
$186.17
$190.53
$197.62
$203.44
$206.35
$210.71
$215.08
$217.80
$220.71
$222.17
$223.62
$225.08
$226.53
$229.44
$232.35
$236.71
$240.89
$246.71
$253.98
$262.53
$272.71
$284.16
$297.25
$310.16
$324.70
$339.07
$354.88
$370.88
$388.16
$405.43
$424.15
$443.06
$463.24
$473.24
$493.42
$510.87
$522.33
$536.69
$545.42
$545.42
$
BluePreferred
HSA Silver
$1,500
BlueChoice
HSA Silver
$1,300
$125.26
$197.25
$197.25
$197.25
$197.25
$198.04
$201.99
$206.72
$214.41
$220.73
$223.88
$228.62
$233.35
$236.31
$239.47
$241.04
$242.62
$244.20
$245.78
$248.93
$252.09
$256.82
$261.36
$267.67
$275.56
$284.83
$295.88
$308.31
$322.51
$336.51
$352.29
$367.88
$385.04
$402.40
$421.14
$439.87
$460.19
$480.71
$502.60
$513.45
$535.34
$554.28
$566.71
$582.29
$591.76
$591.76
$111.66
$175.84
$175.84
$175.84
$175.84
$176.55
$180.06
$184.28
$191.14
$196.77
$199.58
$203.80
$208.02
$210.66
$213.48
$214.88
$216.29
$217.70
$219.10
$221.92
$224.73
$228.95
$232.99
$238.62
$245.65
$253.92
$263.77
$274.84
$287.51
$299.99
$314.06
$327.95
$343.25
$358.72
$375.43
$392.13
$410.24
$428.53
$448.05
$457.72
$477.24
$494.12
$505.20
$519.09
$527.53
$527.53
$117.37
$184.84
$184.84
$184.84
$184.84
$185.58
$189.27
$193.71
$200.92
$206.83
$209.79
$214.23
$218.66
$221.44
$224.39
$225.87
$227.35
$228.83
$230.31
$233.26
$236.22
$240.66
$244.91
$250.82
$258.22
$266.91
$277.26
$288.90
$302.21
$315.33
$330.12
$344.72
$360.80
$377.07
$394.63
$412.19
$431.23
$450.45
$470.97
$481.13
$501.65
$519.39
$531.04
$545.64
$554.51
$554.51
$
$
$
*Also available to people who have received certification from an Exchange that they are exempt from the individual mandate because they do not have an
affordable coverage option or because they qualify for a hardship exemption. Visit your public Exchange for more details.
** If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
22
Consumer Health Insurance Plans 2015
■
Maryland
Allegany, Carroll, Frederick, Garrett and Washington Counties
Age
Gold Level Plans
Platinum Level Plans
HealthyBlue
Gold
$1,500
BlueChoice
Gold
$1,000
BluePreferred
Gold
$500
BlueChoice
Gold
$0
HealthyBlue
Platinum
$0
BluePreferred
Platinum
$0
$154.83
$243.83
$243.83
$243.83
$243.83
$244.80
$249.68
$255.53
$265.04
$272.84
$276.74
$282.60
$288.45
$292.11
$296.01
$297.96
$299.91
$301.86
$303.81
$307.71
$311.61
$317.46
$323.07
$330.87
$340.63
$352.09
$365.74
$381.10
$398.66
$415.97
$435.48
$454.74
$475.95
$497.41
$520.57
$543.74
$568.85
$594.21
$621.27
$634.68
$661.75
$685.15
$700.52
$719.78
$731.48
$731.48
$135.93
$214.06
$214.06
$214.06
$214.06
$214.91
$219.20
$224.33
$232.68
$239.53
$242.96
$248.09
$253.23
$256.44
$259.87
$261.58
$263.29
$265.00
$266.72
$270.14
$273.57
$278.70
$283.63
$290.48
$299.04
$309.10
$321.09
$334.57
$349.98
$365.18
$382.31
$399.22
$417.84
$436.68
$457.01
$477.35
$499.40
$521.66
$545.42
$557.19
$580.95
$601.50
$614.99
$631.90
$642.17
$642.17
$166.17
$261.68
$261.68
$261.68
$261.68
$262.73
$267.96
$274.24
$284.45
$292.82
$297.01
$303.29
$309.57
$313.50
$317.68
$319.78
$321.87
$323.96
$326.06
$330.24
$334.43
$340.71
$346.73
$355.10
$365.57
$377.87
$392.53
$409.01
$427.85
$446.43
$467.37
$488.04
$510.81
$533.83
$558.69
$583.55
$610.51
$637.72
$666.77
$681.16
$710.21
$735.33
$751.82
$772.49
$785.05
$785.05
$140.81
$221.75
$221.75
$221.75
$221.75
$222.64
$227.07
$232.39
$241.04
$248.14
$251.69
$257.01
$262.33
$265.66
$269.20
$270.98
$272.75
$274.53
$276.30
$279.85
$283.40
$288.72
$293.82
$300.91
$309.78
$320.21
$332.62
$346.59
$362.56
$378.30
$396.04
$413.56
$432.85
$452.37
$473.43
$494.50
$517.34
$540.40
$565.02
$577.21
$601.83
$623.12
$637.09
$654.60
$665.25
$665.25
$184.87
$291.14
$291.14
$291.14
$291.14
$292.30
$298.12
$305.11
$316.47
$325.78
$330.44
$337.43
$344.41
$348.78
$353.44
$355.77
$358.10
$360.43
$362.76
$367.41
$372.07
$379.06
$385.76
$395.07
$406.72
$420.40
$436.70
$455.05
$476.01
$496.68
$519.97
$542.97
$568.30
$593.92
$621.58
$649.23
$679.22
$709.50
$741.82
$757.83
$790.14
$818.09
$836.44
$859.43
$873.41
$873.41
$202.94
$319.59
$319.59
$319.59
$319.59
$320.86
$327.26
$334.93
$347.39
$357.62
$362.73
$370.40
$378.07
$382.86
$387.98
$390.53
$393.09
$395.65
$398.20
$403.32
$408.43
$416.10
$423.45
$433.68
$446.46
$461.48
$479.38
$499.51
$522.52
$545.21
$570.78
$596.03
$623.83
$651.95
$682.31
$712.67
$745.59
$778.83
$814.30
$831.88
$867.35
$898.03
$918.17
$943.42
$958.76
$958.76
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+*
$
$
$
$
$
A plan just for yourself?
For each plan you’re
interested in:
1. Go down the plan column
to the row that matches
your age when coverage
will begin
2. Circle that premium
3. Repeat for all of the plans
you’re interested in
Family plan? Use the
same county rate table.
1. Find the age rows in
the plan column and
circle the rates for:
You
Your spouse
Your three oldest
kids under 21 (all are
covered, but only
three count toward
overall rate)
All kids 21-25
2. Add up everyone’s rate
3. Repeat for each plan
you want to consider
$
* If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
Consumer Health Insurance Plans 2015
■
Maryland
23
Calvert, Caroline, Cecil, Charles, Dorchester, Kent, Queen Anne’s, St. Mary’s,
Somerset, Talbot, Wicomico and Worcester Counties
Age
Bronze Level Plans
BlueChoice BlueChoice BlueChoice BlueChoice
Young Adult HSA Bronze Plus Bronze HSA Bronze
$6,600
$6,000
$5,500
$4,000
$70.65
$111.26
$111.26
$111.26
$111.26
$111.70
$113.93
$116.60
$120.94
$124.50
$126.28
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+**
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
$
$80.54
$126.83
$126.83
$126.83
$126.83
$127.34
$129.87
$132.92
$137.86
$141.92
$143.95
$146.99
$150.04
$151.94
$153.97
$154.98
$156.00
$157.01
$158.03
$160.06
$162.09
$165.13
$168.05
$172.11
$177.18
$183.14
$190.24
$198.23
$207.37
$216.37
$226.52
$236.54
$247.57
$258.73
$270.78
$282.83
$295.89
$309.08
$323.16
$330.14
$344.21
$356.39
$364.38
$374.40
$380.49
$380.49
$
$94.61
$149.00
$149.00
$149.00
$149.00
$149.59
$152.57
$156.15
$161.96
$166.73
$169.11
$172.69
$176.26
$178.50
$180.88
$182.07
$183.26
$184.46
$185.65
$188.03
$190.42
$193.99
$197.42
$202.19
$208.15
$215.15
$223.49
$232.88
$243.61
$254.19
$266.11
$277.88
$290.84
$303.95
$318.10
$332.26
$347.61
$363.10
$379.64
$387.83
$404.37
$418.68
$428.06
$439.83
$446.99
$446.99
Silver Level Plans
BluePreferred
HSA Bronze
$3,500
$84.12
$132.47
$132.47
$132.47
$132.47
$133.00
$135.65
$138.83
$144.00
$148.24
$150.36
$153.53
$156.71
$158.70
$160.82
$161.88
$162.94
$164.00
$165.06
$167.18
$169.30
$172.48
$175.53
$179.76
$185.06
$191.29
$198.71
$207.05
$216.59
$226.00
$236.59
$247.06
$258.59
$270.24
$282.83
$295.41
$309.06
$322.83
$337.54
$344.82
$359.53
$372.25
$380.59
$391.06
$397.42
$397.42
$
$
$107.44
$169.20
$169.20
$169.20
$169.20
$169.88
$173.26
$177.32
$183.92
$189.34
$192.04
$196.10
$200.16
$202.70
$205.41
$206.76
$208.12
$209.47
$210.82
$213.53
$216.24
$220.30
$224.19
$229.61
$236.37
$244.33
$253.80
$264.46
$276.64
$288.66
$302.19
$315.56
$330.28
$345.17
$361.24
$377.32
$394.75
$412.34
$431.12
$440.43
$459.21
$475.45
$486.11
$499.48
$507.60
$507.60
$
BlueChoice BlueChoice
Plus Silver
Silver
$2,500
$2,000
$122.89
$193.54
$193.54
$193.54
$193.54
$194.31
$198.18
$202.82
$210.37
$216.57
$219.66
$224.31
$228.95
$231.86
$234.95
$236.50
$238.05
$239.60
$241.14
$244.24
$247.34
$251.98
$256.43
$262.63
$270.37
$279.46
$290.30
$302.50
$316.43
$330.17
$345.65
$360.94
$377.78
$394.81
$413.20
$431.58
$451.52
$471.65
$493.13
$503.77
$525.25
$543.83
$556.03
$571.32
$580.61
$580.61
$
BluePreferred
HSA Silver
$1,500
BlueChoice
HSA Silver
$1,300
$133.34
$209.98
$209.98
$209.98
$209.98
$210.82
$215.02
$220.06
$228.25
$234.97
$238.33
$243.37
$248.41
$251.55
$254.91
$256.59
$258.27
$259.95
$261.63
$264.99
$268.35
$273.39
$278.22
$284.94
$293.34
$303.21
$314.97
$328.20
$343.32
$358.22
$375.02
$391.61
$409.88
$428.36
$448.31
$468.25
$489.88
$511.72
$535.03
$546.58
$569.88
$590.04
$603.27
$619.86
$629.94
$629.94
$118.87
$187.19
$187.19
$187.19
$187.19
$187.94
$191.68
$196.17
$203.47
$209.46
$212.46
$216.95
$221.44
$224.25
$227.25
$228.75
$230.24
$231.74
$233.24
$236.23
$239.23
$243.72
$248.03
$254.02
$261.50
$270.30
$280.78
$292.58
$306.05
$319.34
$334.32
$349.11
$365.39
$381.87
$399.65
$417.43
$436.71
$456.18
$476.96
$487.25
$508.03
$526.00
$537.79
$552.58
$561.57
$561.57
$124.94
$196.76
$196.76
$196.76
$196.76
$197.55
$201.48
$206.21
$213.88
$220.18
$223.33
$228.05
$232.77
$235.72
$238.87
$240.44
$242.02
$243.59
$245.17
$248.31
$251.46
$256.18
$260.71
$267.01
$274.88
$284.13
$295.14
$307.54
$321.71
$335.68
$351.42
$366.96
$384.08
$401.40
$420.09
$438.78
$459.05
$479.51
$501.35
$512.17
$534.01
$552.90
$565.30
$580.84
$590.29
$590.29
$
$
$
*Also available to people who have received certification from an Exchange that they are exempt from the individual mandate because they do not have an
affordable coverage option or because they qualify for a hardship exemption. Visit your public Exchange for more details.
** If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
24
Consumer Health Insurance Plans 2015
■
Maryland
Calvert, Caroline, Cecil, Charles, Dorchester, Kent, Queen Anne’s, St. Mary’s,
Somerset, Talbot, Wicomico and Worcester Counties
Age
Gold Level Plans
Platinum Level Plans
HealthyBlue
Gold
$1,500
BlueChoice
Gold
$1,000
BluePreferred
Gold
$500
BlueChoice
Gold
$0
HealthyBlue
Platinum
$0
BluePreferred
Platinum
$0
$164.82
$259.56
$259.56
$259.56
$259.56
$260.60
$265.79
$272.02
$282.14
$290.45
$294.60
$300.83
$307.06
$310.95
$315.10
$317.18
$319.26
$321.33
$323.41
$327.56
$331.72
$337.94
$343.91
$352.22
$362.60
$374.80
$389.34
$405.69
$424.38
$442.81
$463.57
$484.08
$506.66
$529.50
$554.16
$578.81
$605.55
$632.54
$661.35
$675.63
$704.44
$729.36
$745.71
$766.22
$778.67
$778.67
$144.70
$227.87
$227.87
$227.87
$227.87
$228.78
$233.34
$238.81
$247.69
$254.98
$258.63
$264.10
$269.57
$272.99
$276.63
$278.46
$280.28
$282.10
$283.92
$287.57
$291.22
$296.68
$301.93
$309.22
$318.33
$329.04
$341.80
$356.16
$372.56
$388.74
$406.97
$424.97
$444.80
$464.85
$486.50
$508.15
$531.62
$555.32
$580.61
$593.14
$618.43
$640.31
$654.67
$672.67
$683.60
$683.60
$176.89
$278.57
$278.57
$278.57
$278.57
$279.68
$285.25
$291.94
$302.80
$311.72
$316.17
$322.86
$329.54
$333.72
$338.18
$340.41
$342.64
$344.86
$347.09
$351.55
$356.01
$362.69
$369.10
$378.01
$389.16
$402.25
$417.85
$435.40
$455.46
$475.23
$497.52
$519.53
$543.76
$568.28
$594.74
$621.20
$649.89
$678.87
$709.79
$725.11
$756.03
$782.77
$800.32
$822.33
$835.70
$835.70
$149.90
$236.06
$236.06
$236.06
$236.06
$237.00
$241.72
$247.39
$256.59
$264.15
$267.92
$273.59
$279.25
$282.79
$286.57
$288.46
$290.35
$292.24
$294.13
$297.90
$301.68
$307.34
$312.77
$320.33
$329.77
$340.86
$354.08
$368.95
$385.95
$402.71
$421.60
$440.24
$460.78
$481.55
$503.98
$526.40
$550.72
$575.27
$601.47
$614.45
$640.65
$663.32
$678.19
$696.84
$708.17
$708.17
$196.80
$309.92
$309.92
$309.92
$309.92
$311.16
$317.36
$324.80
$336.88
$346.80
$351.76
$359.20
$366.63
$371.28
$376.24
$378.72
$381.20
$383.68
$386.16
$391.12
$396.08
$403.52
$410.64
$420.56
$432.96
$447.52
$464.88
$484.40
$506.72
$528.72
$553.52
$578.00
$604.96
$632.24
$661.68
$691.12
$723.04
$755.27
$789.67
$806.72
$841.12
$870.87
$890.40
$914.88
$929.76
$929.76
$216.03
$340.20
$340.20
$340.20
$340.20
$341.56
$348.37
$356.53
$369.80
$380.69
$386.13
$394.30
$402.46
$407.56
$413.01
$415.73
$418.45
$421.17
$423.89
$429.34
$434.78
$442.95
$450.77
$461.66
$475.26
$491.25
$510.31
$531.74
$556.23
$580.39
$607.60
$634.48
$664.08
$694.02
$726.33
$758.65
$793.69
$829.08
$866.84
$885.55
$923.31
$955.97
$977.40
$1,004.28
$1,020.61
$1,020.61
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+*
$
$
$
$
$
A plan just for yourself?
For each plan you’re
interested in:
1. Go down the plan column
to the row that matches
your age when coverage
will begin
2. Circle that premium
3. Repeat for all of the plans
you’re interested in
Family plan? Use the
same county rate table.
1. Find the age rows in
the plan column and
circle the rates for:
You
Your spouse
Your three oldest
kids under 21 (all are
covered, but only
three count toward
overall rate)
All kids 21-25
2. Add up everyone’s rate
3. Repeat for each plan
you want to consider
$
* If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
Consumer Health Insurance Plans 2015
■
Maryland
25
Montgomery and Prince George’s Counties
Age
Bronze Level Plans
BlueChoice BlueChoice BlueChoice BlueChoice
Young Adult HSA Bronze Plus Bronze HSA Bronze
$6,600
$6,000
$5,500
$4,000
$67.08
$105.64
$105.64
$105.64
$105.64
$106.06
$108.17
$110.71
$114.83
$118.21
$119.90
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+**
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
$
$76.47
$120.42
$120.42
$120.42
$120.42
$120.91
$123.31
$126.20
$130.90
$134.75
$136.68
$139.57
$142.46
$144.27
$146.19
$147.16
$148.12
$149.08
$150.05
$151.97
$153.90
$156.79
$159.56
$163.41
$168.23
$173.89
$180.64
$188.22
$196.89
$205.44
$215.08
$224.59
$235.07
$245.66
$257.10
$268.54
$280.95
$293.47
$306.84
$313.46
$326.83
$338.39
$345.98
$355.49
$361.27
$361.27
$
$89.83
$141.47
$141.47
$141.47
$141.47
$142.04
$144.87
$148.26
$153.78
$158.30
$160.57
$163.96
$167.36
$169.48
$171.74
$172.88
$174.01
$175.14
$176.27
$178.54
$180.80
$184.19
$187.45
$191.97
$197.63
$204.28
$212.21
$221.12
$231.30
$241.35
$252.67
$263.84
$276.15
$288.60
$302.04
$315.48
$330.05
$344.76
$360.47
$368.25
$383.95
$397.53
$406.44
$417.62
$424.41
$424.41
Silver Level Plans
BluePreferred
HSA Bronze
$3,500
$79.87
$125.78
$125.78
$125.78
$125.78
$126.28
$128.80
$131.82
$136.72
$140.75
$142.76
$145.78
$148.80
$150.69
$152.70
$153.70
$154.71
$155.72
$156.72
$158.74
$160.75
$163.77
$166.66
$170.69
$175.72
$181.63
$188.67
$196.60
$205.65
$214.58
$224.65
$234.58
$245.53
$256.59
$268.54
$280.49
$293.45
$306.53
$320.49
$327.41
$341.37
$353.45
$361.37
$371.31
$377.34
$377.34
$
$
$102.02
$160.66
$160.66
$160.66
$160.66
$161.30
$164.51
$168.37
$174.63
$179.77
$182.34
$186.20
$190.06
$192.47
$195.04
$196.32
$197.61
$198.89
$200.18
$202.75
$205.32
$209.17
$212.87
$218.01
$224.44
$231.99
$240.98
$251.10
$262.67
$274.08
$286.93
$299.62
$313.60
$327.74
$343.00
$358.26
$374.81
$391.52
$409.35
$418.19
$436.02
$451.44
$461.56
$474.25
$481.97
$481.97
$
BlueChoice BlueChoice
Plus Silver
Silver
$2,500
$2,000
$116.69
$183.76
$183.76
$183.76
$183.76
$184.50
$188.17
$192.58
$199.75
$205.63
$208.57
$212.98
$217.39
$220.15
$223.09
$224.56
$226.03
$227.50
$228.97
$231.91
$234.85
$239.26
$243.48
$249.36
$256.71
$265.35
$275.64
$287.22
$300.45
$313.50
$328.20
$342.71
$358.70
$374.87
$392.33
$409.79
$428.71
$447.82
$468.22
$478.33
$498.73
$516.37
$527.94
$542.46
$551.28
$551.28
$
BluePreferred
HSA Silver
$1,500
BlueChoice
HSA Silver
$1,300
$126.60
$199.37
$199.37
$199.37
$199.37
$200.17
$204.16
$208.94
$216.72
$223.10
$226.29
$231.07
$235.86
$238.85
$242.04
$243.64
$245.23
$246.83
$248.42
$251.61
$254.80
$259.58
$264.17
$270.55
$278.53
$287.90
$299.06
$311.62
$325.98
$340.13
$356.08
$371.83
$389.18
$406.72
$425.66
$444.60
$465.14
$485.87
$508.00
$518.97
$541.10
$560.24
$572.80
$588.55
$598.12
$598.12
$112.86
$177.74
$177.74
$177.74
$177.74
$178.45
$182.00
$186.27
$193.20
$198.89
$201.73
$206.00
$210.26
$212.93
$215.77
$217.19
$218.61
$220.04
$221.46
$224.30
$227.15
$231.41
$235.50
$241.19
$248.30
$256.65
$266.60
$277.80
$290.60
$303.22
$317.44
$331.48
$346.94
$362.58
$379.46
$396.35
$414.66
$433.14
$452.87
$462.64
$482.37
$499.44
$510.63
$524.67
$533.21
$533.21
$118.63
$186.83
$186.83
$186.83
$186.83
$187.57
$191.31
$195.79
$203.08
$209.06
$212.05
$216.53
$221.01
$223.82
$226.81
$228.30
$229.79
$231.29
$232.78
$235.77
$238.76
$243.25
$247.54
$253.52
$260.99
$269.78
$280.24
$292.01
$305.46
$318.72
$333.67
$348.43
$364.68
$381.12
$398.87
$416.62
$435.86
$455.29
$476.03
$486.31
$507.04
$524.98
$536.75
$551.51
$560.48
$560.48
$
$
$
*Also available to people who have received certification from an Exchange that they are exempt from the individual mandate because they do not have an
affordable coverage option or because they qualify for a hardship exemption. Visit your public Exchange for more details.
** If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
26
Consumer Health Insurance Plans 2015
■
Maryland
Montgomery and Prince George’s Counties
Age
Gold Level Plans
Platinum Level Plans
HealthyBlue
Gold
$1,500
BlueChoice
Gold
$1,000
BluePreferred
Gold
$500
BlueChoice
Gold
$0
HealthyBlue
Platinum
$0
BluePreferred
Platinum
$0
$156.50
$246.45
$246.45
$246.45
$246.45
$247.43
$252.36
$258.28
$267.89
$275.78
$279.72
$285.63
$291.55
$295.25
$299.19
$301.16
$303.13
$305.10
$307.08
$311.02
$314.96
$320.88
$326.55
$334.43
$344.29
$355.87
$369.67
$385.20
$402.94
$420.44
$440.16
$459.63
$481.07
$502.76
$526.17
$549.58
$574.97
$600.60
$627.95
$641.51
$668.86
$692.52
$708.05
$727.52
$739.35
$739.35
$137.39
$216.36
$216.36
$216.36
$216.36
$217.23
$221.55
$226.75
$235.18
$242.11
$245.57
$250.76
$255.95
$259.20
$262.66
$264.39
$266.12
$267.85
$269.58
$273.05
$276.51
$281.70
$286.68
$293.60
$302.25
$312.42
$324.54
$338.17
$353.75
$369.11
$386.42
$403.51
$422.33
$441.37
$461.93
$482.48
$504.77
$527.27
$551.28
$563.18
$587.20
$607.97
$621.60
$638.69
$649.08
$649.08
$167.96
$264.50
$264.50
$264.50
$264.50
$265.56
$270.85
$277.19
$287.51
$295.97
$300.20
$306.55
$312.90
$316.87
$321.10
$323.22
$325.33
$327.45
$329.56
$333.80
$338.03
$344.38
$350.46
$358.92
$369.50
$381.93
$396.75
$413.41
$432.45
$451.23
$472.39
$493.29
$516.30
$539.57
$564.70
$589.83
$617.07
$644.58
$673.94
$688.49
$717.85
$743.24
$759.90
$780.80
$793.49
$793.49
$142.32
$224.13
$224.13
$224.13
$224.13
$225.03
$229.51
$234.89
$243.63
$250.81
$254.39
$259.77
$265.15
$268.51
$272.10
$273.89
$275.68
$277.48
$279.27
$282.86
$286.44
$291.82
$296.98
$304.15
$313.11
$323.65
$336.20
$350.32
$366.46
$382.37
$400.30
$418.01
$437.51
$457.23
$478.53
$499.82
$522.90
$546.21
$571.09
$583.42
$608.30
$629.82
$643.94
$661.64
$672.40
$672.40
$186.86
$294.27
$294.27
$294.27
$294.27
$295.44
$301.33
$308.39
$319.87
$329.28
$333.99
$341.06
$348.12
$352.53
$357.24
$359.59
$361.95
$364.30
$366.66
$371.36
$376.07
$383.14
$389.90
$399.32
$411.09
$424.92
$441.40
$459.94
$481.13
$502.02
$525.56
$548.81
$574.41
$600.30
$628.26
$656.22
$686.52
$717.13
$749.79
$765.98
$798.64
$826.89
$845.43
$868.68
$882.80
$882.80
$205.12
$323.02
$323.02
$323.02
$323.02
$324.31
$330.77
$338.53
$351.12
$361.46
$366.63
$374.38
$382.13
$386.98
$392.15
$394.73
$397.32
$399.90
$402.48
$407.65
$412.82
$420.57
$428.00
$438.34
$451.26
$466.44
$484.53
$504.88
$528.14
$551.07
$576.92
$602.44
$630.54
$658.96
$689.65
$720.34
$753.61
$787.20
$823.06
$840.83
$876.68
$907.69
$928.04
$953.56
$969.06
$969.06
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+*
$
$
$
$
$
A plan just for yourself?
For each plan you’re
interested in:
1. Go down the plan column
to the row that matches
your age when coverage
will begin
2. Circle that premium
3. Repeat for all of the plans
you’re interested in
Family plan? Use the
same county rate table.
1. Find the age rows in
the plan column and
circle the rates for:
You
Your spouse
Your three oldest
kids under 21 (all are
covered, but only
three count toward
overall rate)
All kids 21-25
2. Add up everyone’s rate
3. Repeat for each plan
you want to consider
$
* If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
Consumer Health Insurance Plans 2015
■
Maryland
27
Enroll today
Four ways to enroll in your
new CareFirst plan
At this point, you should have decided on the CareFirst plan
that’s best for your needs. You’re almost done!
If you don’t think you’re eligible for a subsidy, there are four ways
you can enroll in your new plan right now.
Enroll online at www.carefirst.com/individual
■■ get instant confirmation
■■ have access to real-time help via:
Click-to-Call
Click-to-Chat
Chloe, our digital rep!
Fill out and mail this paper application using the
pre-paid envelope. We’ll mail you a confirmation
and a bill.
Enroll through your broker.
Whether you’re applying for the first
time or need to re-evaluate your
financial assistance, check out our
subsidy estimator at
www.carefirst.com/individual.
Answer a few questions and click on
the button “I am interested in a
subsidy from the government,” before
clicking “Next.” We can even show
you how much you would pay for your
CareFirst plan if you qualify for
financial assistance!
Visit one of our district offices listed on the next page
to enroll in person and get your questions answered
face-to-face.
Still undecided about which
CareFirst plan is best for you?
Give us a call at 410-356-8000. Toll free at 800-544-8703.
We’ll answer your call seven days a week from 8 a.m.–8 p.m.
Or, set up an appointment with one of our district offices listed
on the next page.
Need language assistance?
Use the same number for our bilingual services.
Consumer Health Insurance Plans 2015
■
Maryland
29
Paying for your plan
Payment is due on or before the date your coverage begins in order
for your benefits to start.
Convenient e-Billing
When you set up automated recurring monthly premium payments,
your first payment and each payment after, will be sent to CareFirst
automatically. You can also set it up in section seven of this application or
at www.carefirst.com/myaccount where you can also view and pay bills
and monitor payments 24/7.
When your coverage will start
When you enroll through CareFirst, the effective date is the date your
coverage begins.
Enroll:
For effective date of:
Nov. 18 – Dec. 15 . . . . . . . . . . . . Jan. 1, 2015
Dec. 16 – Jan. 15 . . . . . . . . . . . . Feb. 1, 2015
Jan. 16 – Feb. 15 . . . . . . . . . . . . Mar. 1, 2015
IMPORTANT: ACA requires that everyone must have health coverage
that meets ACA requirements at all times. Going without coverage for
more than three months could mean you have to pay a penalty. You
may have to pay a penalty for any days you are uninsured after Open
Enrollment which ends on February 15, 2015. Once Open Enrollment
ends, you can only buy health insurance for the rest of 2015 if you meet
the criteria of having a qualifying life event (marriage, baby, layoff, etc.).
District office locations
and business hours
Annapolis District Office
151 West Street Suite 101
Annapolis, MD 21401
410-268-6488
8:30 a.m–4:30 p.m.
Cumberland District Office
10 Commerce Drive
Cumberland, MD, 21502
301-724-1313
8:30 a.m–4:30 p.m.
Easton District Office
301 Bay Street Plaza, Suite 401
Easton, MD 21601
410-822-1850
8:30 a.m–4:30 p.m.
Frederick District Office
2405 Whittier Drive, Suite 100
Frederick, MD 21702
301-663-3138
8:30 a.m–4:30 p.m.
Hagerstown District Office
182-184 Eastern Blvd. North
Hagerstown, MD 21740
301-733-5995
8:30 a.m–4:30 p.m.
Salisbury District Office
224 Phillip Morris Dr., Suite 106
Salisbury, MD 21804
410-742-3274
8:30 a.m–4:30 p.m.
CareFirst Lobby Services
10802 Red Run Blvd
Owings, Mills, MD 21117
No phone number—
Walk-ins only
8:30 a.m–4:30 p.m.
When you’re ready to review a listing of providers, visit
www.carefirst.com/findadoc. If you’d rather have a printed
directory, give us a call and we’ll send you one.
30
Consumer Health Insurance Plans 2015
■
Maryland
Individual Application
Maryland Residents
A private not-for-profit health service plan
CareFirst of Maryland, Inc. • 10455 Mill Run Circle, Owings Mills, MD 21117
Group Hospitalization and Medical Services, Inc. • CareFirst BlueChoice, Inc. • 840 First Street, NE, Washington, DC 20065
INSTRUCTIONS
1. Please fill out all applicable spaces on this application.
Print or type all information.
2. Sign and return this application in the postage-paid
return envelope if provided, or mail to:
Mailroom Administrator
P.O. Box 14651, Lexington, KY 40512
Give careful attention to all questions in this application.
Accurate, complete information is necessary before
your application can be processed. If incomplete, the
application will be returned and your coverage will be
delayed.
Are you applying for new coverage or are you making changes
to a current policy? Check one box.
New coverage
Making changes
1. PRIMARY APPLICANT INFORMATION (The primary applicant will be the Head of Household)
Last Name
First Name
Initial
Social Security #
Residence Address: (Number and Street, Apt #)
City and State
Zip Code (9-digit, if known)
Billing Address, if different: (Number and Street, Apt #)
City and State
Zip Code (9-digit, if known)
Residence County
Sex
Male
Date of Birth
/
/
Female
Home Phone
Work/Cell Phone
(
(
)
Marital Status
Single
Married
Domestic Partner
)
2. ENROLLING FAMILY MEMBER(S) (Complete only if you are enrolling a Spouse, Partner or Dependent(s) to your plan)
Last Name
First Name
M.I.
Relationship
Social Security #
Date of Birth
Sex
Spouse
M
F
Domestic
Partner
M
F
Dependent 1
M
F
Dependent 2
M
F
Dependent 3
M
F
Dependent 4
M
F
Dependent 5
M
F
Dependent 6
M
F
Dependent 7
M
F
Dependent 8
M
F
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
MMDAP (4/14)
1
Consumer Health Insurance Plans 2015
■
Maryland
31
CDS1099-1P (8/14)
3. PLAN SELECTION (Check one)
In-Network
Deductible
Out-of-Network
Deductible
Individual: $6,600
Family: $13,200
N/A
Plan Name
If you are applying for one of the following Health Maintenance Organization (HMO)
plans administered by CareFirst BlueChoice, Inc., please check here
BlueChoice Young Adult $6,600*
BlueChoice Young Adult is only available for individuals under age 30. Some exceptions may apply.
Individual: $6,000
Family: $12,000
Individual: $4,000
Family: $8,000
Individual: $2,000
Family: $4,000
Individual: $1,300
Family: $2,600
Individual: $1,000
Family: $2,000
Individual: $0
Family: $0
BlueChoice HSA Bronze $6,000*
BlueChoice HSA Bronze $4,000*
BlueChoice Silver $2,000*
BlueChoice HSA Silver $1,300*
BlueChoice Gold $1,000*
BlueChoice Gold $0*
N/A
N/A
N/A
N/A
N/A
N/A
If you are applying for one of the following Point-of-Service (POS) plans, please note that POS plans offer two benefit
levels: In-Network HMO-level benefits administered by CareFirst BlueChoice, Inc. and Out-of-Network indemnity-level benefits
administered by either:
Group Hospitalization and Medical Services, Inc. (for residents of Montgomery or Prince George’s counties), please check here ; or
CareFirst of Maryland, Inc. (for residents of Baltimore City or any other county in the state of Maryland), please check here
Individual: $5,500
Individual: $6,350
BlueChoice Plus Bronze $5,500*
Family: $11,000
Family: $12,700
Individual: $2,500
Individual: $5,000
BlueChoice Plus Silver $2,500*
Family: $5,000
Family: $10,000
Individual: $1,500
Individual: $2,500
HealthyBlue Gold $1,500*
Family: $3,000
Family: $5,000
Individual: $0
Individual: $1,000
HealthyBlue Platinum $0*
Family: $0
Family: $2,000
If you are applying for one of the following Preferred Provider Organization (PPO) plans, benefits are either administered by:
Group Hospitalization and Medical Services, Inc. (for residents of Montgomery or Prince George’s counties), please check here ; or
CareFirst of Maryland, Inc. (for residents of Baltimore City or any other county in the state of Maryland), please check here
Individual: $3,500
Family: $7,000
Individual: $1,500
Family: $3,000
Individual: $500
Family: $1,000
Individual: $0
Family: $0
BluePreferred HSA Bronze $3,500
BluePreferred HSA Silver $1,500
BluePreferred Gold $500
BluePreferred Platinum $0
Individual: $7,000
Family: $14,000
Individual: $3,000
Family: $6,000
Individual: $1,000
Family: $2,000
Individual: $1,000
Family: $2,000
Important Deductible Information:
For HSA Plans (HSA listed in plan name): Single party applications: the Individual Deductible must be met before full benefits
will begin. Multi-party applications: the Family Deductible must be met before full benefits will be available to any member on the
policy. Once the Family deductible has been met, full benefits will become available to everyone covered.
For non-HSA Plans (HSA is not listed in plan name): Single party applications: the Individual Deductible must be met before
full benefits will begin. Multi-party applications: if one member on the policy meets the Individual Deductible, full benefits will
begin for that member. That member will not be able to contribute more than the Individual Deductible amount towards the Family
Deductible. Once the Family Deductible has been met, full benefits will be available to all members on the policy.
Please Note: Coverage will begin immediately for preventive benefits as they are not subject to a deductible. Other benefits, as
specified in the member contract, also may be covered without having to meet a deductible first. In-network and out-of-network
(if applicable) deductible expenses will not be applied to each other.
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4. PRIMARY CARE PHYSICIAN INFORMATION
*If you selected a BlueChoice or HealthyBlue plan in Section 3, please select a Primary Care Physician from the CareFirst
BlueChoice Directory available at www.carefirst.com/doctor. Indicate the PCP ID number for all enrolling applicants below:
Applicant Name
PCP ID
Spouse/Domestic Partner
PCP ID
Eligible Dependent Name(s)
PCP ID
5. OTHER INSURANCE INFORMATION — COORDINATION OF BENEFITS
THE PURPOSE OF THIS SECTION IS TO COORDINATE BENEFITS APPROPRIATELY WITH OTHER CARRIERS. IF YOU HAVE OTHER
INSURANCE, FAILURE TO COMPLETE THIS SECTION MAY CAUSE DELAYS IN PROCESSING ANY CLAIMS SUBMITTED.
Yes
No
1. Is anyone listed on this application enrolled in, covered by or eligible for Medicare?
If yes, please provide the following:
Name of family member(s)
Medicare No
Effective Date
2. Is anyone listed on this application covered by other health insurance, including other Blue Cross and Blue Shield coverage?
If yes, please provide the following:
Yes
No
Do you qualify for a Limited Open Enrollment Period based on one of the triggering events listed below? If YES,
please select the triggering event to determine your eligibility. You will be required to provide documentation as
proof of your triggering event. If NO, please skip to Section 7.
Yes
No
1. Within the last 60 days, have you married, or entered a domestic partnership? Had a birth, adopted, or been
granted court-appointed testamentary of a child or qualified dependent? Had a child placed with you as a foster
child by an accredited foster child agency? (Note: The foster child is not eligible for coverage.)
Yes
No
Have you experienced an error in enrollment by the Maryland Health Connection or by the Department of Health
and Human Services?
Yes
No
Were you enrolled in a qualified health plan in which the plan substantially violated a material provision of its
contract?
Yes
No
Have you or your dependents become newly eligible or ineligible for subsidies?
Yes
No
Have you gained access to new Qualified Health Plans as a result of a permanent move to or within Maryland?
Yes
No
3. Were you covered under a non-calendar year individual health insurance policy and are you within 30 days prior
to or within 30 days after your policy renewal date?
Yes
No
Name of family member(s)
Insurance Company
Policy Number and Type
Effective Date
6. LIMITED OPEN ENROLLMENT ELIGIBILITY
2. Within the last 60 days:
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CDS1099-1P (8/14)
6. LIMITED OPEN ENROLLMENT ELIGIBILITY (continued)
4. In the next 60 days or within the last 60 days: Will your coverage through an employer-sponsored or has your
coverage through an employer-sponsored plan been: discontinued, no longer provide minimum value (plan covers
less than 60% actuarial value), or is unaffordable (employee contribution to plan premium of self-only coverage
exceeds 9.5% of employee’s household income)?
Yes
No
5. In the next 60 days or within the last 60 days: Will you or have you lost minimum essential coverage
(excluding failure to pay premiums and rescissions) or your state-sponsored pregnancy or medically needy
coverage through Medicaid?
Yes
No
6. Have you experienced an error in enrollment or subsidy eligibility due to the misconduct of a non-Exchange
entity? Misconduct includes failure to comply with applicable standards under state or federal law.
Yes
No
7. RECURRING AUTOMATED PREMIUM PAYMENT
CareFirst wants to help you save time! Our standard method of payment for members is recurring automated payment by bank
withdrawal. To take advantage of this time-saving payment option, please fill out the information below.
If you do not wish to set up an automated payment account then please check this box
Information Required for Recurring Automated Payment:
Checking Account
Savings Account
Bank Name:
Routing Number:
Account Number:
Name that appears on the Account:
Sa
m
pl
e
I hereby authorize CareFirst to charge my account for the payment
NAME
0123
of premiums due for an unpaid invoice. If any check draft is
ADDRESS
01-23456789
CITY, STATE ZIP
dishonored for any reason, or drawn after the depositor’s
DATE
authorization has been withdrawn, CareFirst agrees that the
PAY TO THE
ORDER OF
$
financial institution will not be held liable. I understand that nonpayment of premiums due to dishonored auto-draft payment
DOLLARS
BANK NAME
attempts may result in termination of coverage. I also understand
ADDRESS
CITY, STATE ZIP
that if the Primary Applicant elects to pay premium through an
FOR
electronic payment, CareFirst may not debit or charge the amount
of the premium due prior to the premium due date, except as
authorized by the Primary Applicant. For my health care coverage
Bank Routing
Bank Account
Check
Number
Number
Number
to begin, my first payment due will be taken out on the first day of
the requested month of coverage. Future payments will be taken
out on the 6th day of every month, including holidays. Members registered for recurring automated premium payment will not
receive a paper bill in the mail. However, you may view and print your invoice during the recurring automated payment period from
the invoice history online at www.carefirst.com/myaccount.
Signature of Account Holder
X
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8. ELECTRONIC COMMUNICATION CONSENT
CareFirst wants to help you manage your health care information and protect the environment by offering you the option of
electronic communication.
Instead of paper delivery, you can receive electronic notices about your CareFirst health care coverage through email and/or
text messaging by providing your email address and/or cell phone number and consent below.
Electronic notices regarding your CareFirst health care coverage include, but are not limited to:
• Explanation of Benefits Alerts
• Reminders
• Notice of HIPAA Privacy Practices
• Certification of Creditable Coverage
You may also receive information on programs related to your existing products and services along with new products and
services that may be of interest to you.
Please note, you may change your email and consent information anytime by logging into www.carefirst.com/myaccount or by
calling the customer service phone number on your ID card. You can also request a paper copy of electronic notices at any time
by calling the customer service phone number on your ID card.
I understand that to access the information provided electronically through email, I must have the following:
• Internet access;
• An email account that allows me to send and receive emails; and
• Microsoft Explorer 7.0 (or higher) or Firefox 3.0 (or higher), and Adobe Acrobat Reader 4 (or higher).
I understand that to receive notices through text messaging,
• A text messaging plan with my cell phone provider is required; and
• Standard text messaging rates will apply.
By checking below, I hereby agree to electronic delivery of notices, instead of paper delivery by:
Email only
Cell phone text messaging only
Primary Applicant Name
Email and cell phone text messaging
Email Address
Cell Phone Number
Alternate Email Address
Alternate Cell Phone Number
Spouse / Domestic Partner Name
Email Address
Cell Phone Number
Eligible Dependent Name(s)
Email Address
Cell Phone Number
CareFirst will not sell your email or phone number to any third party and we do not share it with third parties except for
CareFirst business associates that perform functions on our behalf or to comply with the law.
MMDAP (4/14)
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CDS1099-1P (8/14)
9. CONDITIONS OF ENROLLMENT (Please read this section carefully)
IT IS UNDERSTOOD AND AGREED THAT:
A copy of this application will be provided to the Primary Applicant.
To the best of my knowledge and belief, all statements made on this application are complete, true and correctly recorded. They
are representations that are made to induce the issuance of, and form part of the consideration for a CareFirst policy. CareFirst
will provide 30-days advance written notice of any rescission of coverage if it is determined that the Primary Applicant performed
an act, practice, or omission that constitutes fraud or made an intentional misrepresentation of material fact. CareFirst will refund
any premiums to the Primary Applicant. The Member is responsible for repayment of any claim payment made by CareFirst on the
Member’s behalf.
If you have any questions concerning the benefits and services that are provided by or excluded under this Agreement, please
contact a membership services representative before signing this application.
WARNING: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A
LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS
GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
Date
Signature of Primary Applicant: X
Date
Signature of Applicant 2: X
(Spouse or Domestic Partner)
NOTE: Applications submitted solely on behalf of applicants under the age of 18, where payment of premium is made by the
parent or legal guardian, must be signed by the parent or legal guardian.
Date
Parent or Legal Guardian’s Signature: X
10. RACE, ETHNICITY, LANGUAGE (This information is voluntary)
As required by Maryland law, CareFirst is asking its members to voluntarily provide their race, ethnicity and language attributes. The information provided, while
voluntary, will assist the State of Maryland and CareFirst of Maryland to improve quality of care and access to care thereby reducing health care disparities and
promote better health outcomes. The information you provide will not have a negative impact on any services we provide you. The information is kept strictly
confidential and will not be shared unless required by law to disclose it.
Race
Ethnicity
Preferred Spoken Language*
White/Caucasian
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or
Other Pacific Islander
Other – (To include Multi-Racial)
Decline to answer
Unknown – Could not be determined
Hispanic/Latino/Spanish origin
01 English
02 Albanian
03 Amharic
04 Arabic
05 Burmese
06 Cantonese
07 Chinese
(simplified & traditional)
08 Creole (Haitian)
Last Name
First Name
Race
09 Farsi
10 French (European)
11 Greek
12 Gujarati
13 Hindi
14 Italian
15 Korean
16 Mandarin
17 Portuguese (Brazilian)
Ethnicity
18 Russian
19 Serbian
20 Somali
21 Spanish (Latin America)
22 Tagalog (Filipino)
23 Urdu
24 Vietnamese
98 Other and unspecified languages
99 Unknown
Country of Origin
Preferred Spoken
Language
(*specify number
from above)
Primary Applicant
Spouse/
Domestic Partner
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dependent 6
Dependent 7
Dependent 8
MMDAP (4/14)
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CDS1099-1P (8/14)
FOR OFFICE USE ONLY:
Re-sign and re-date below only if box is checked.
Date
Signature of Primary Applicant: X
Date
Signature of Applicant 2: X
(Spouse or Domestic Partner)
Date
Parent or Legal Guardian’s Signature: X
FOR BROKER USE ONLY:
Name:
NPN#
SSN/Tax ID #
CareFirst-Assigned ID #
Contracted Broker:
Sub-Agent/Sub-Agency:
Writing Agent:
MMDAP (4/14)
7
CDS1099-1P (8/14)
Artwork for Envelope, Business, #10 (4.125" x 9.5")
Layout: # 10 LETTER.LYT IMB.LYT
July 16, 2012
Produced by DAZzle Designer, Version 9.0.05
(c) 1993-2009, Endicia, www.Endicia.com
U.S. Postal Service, Serial #NO
CAREFIRST BLUECROSS BLUESHIELD
CAREFIRST
BLUECROSS BLUESHIELD
PO BOX 14651
PO BOX
14651
LEXINGTON KY 40512-9876
LEXINGTON KY 40512-9876
POSTAGE
WILL
BE
PAID
BY
ADDRESSEE
POSTAGE
WILL
BE
PAID
BY
ADDRESSEE
CAREFIRST BLUECROSS BLUESHIELD
PO BOX 14651
BUSINESS
REPLY
MAILDC
BUSINESS
MAIL
KY REPLY
40512-9876
FIRLEXINGTON
ST-CLASSMAIL
MAILPERMIT
PERMIT
NO11562
11562WASHINGTON
WASHINGTONDC
FIRST-CLASS
NO.
POSTAGE WILL BE PAID BY ADDRESSEE
FIRST-CLASS MAIL PERMIT NO. 11562 WASHINGTON DC
BUSINESS REPLY MAIL
IMPORTANT: DO NOT ENLARGE, REDUCE OR MOVE the FIM and POSTNET barcodes. They are only valid as printed!
Special care must be taken to ensure FIM and POSTNET barcode are actual size AND placed properly on the mail piece
to meet both USPS regulations and automation compatibility standards.
IMPORTANT: DO NOT ENLARGE, REDUCE OR MOVE the FIM and POSTNET barcodes. They are only valid as printed!
Special care must be taken to ensure FIM and POSTNET barcode are actual size AND placed properly on the mail piece
to meet both USPS regulations and automation compatibility standards.
Fold and Detach Along Perforation
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
NO POSTAGE
POSTAGE
NO
NECESSARY
NECESSARY
IF MAILED
MAILED
IF
IN THE
IN
UNITED STATES
UNITED
(196
More to smile about
Four optional dental plans
All CareFirst medical plans provide you with pediatric dental benefits.
To get dental coverage for adult members age 19 and older on your
policy, you can choose from four dental plans:
■■ Dental HMO
■■ BlueDental Preferred
■■ Preferred Dental
■■ Preferred Dental Plus
Dental HMO1
Preferred Dental
In-Network
In-Network Only
Out-of-Network Coverage available
Member Pays
Individual Cost Per Day
Less than $.35
Less than $.55
None
None
Over 580 providers in MD, DC, and
northern VA
Over 4,200 providers in MD, DC, and
northern VA
$20 copay per office visit
No charge
$20-$70 copay per office visit
Not covered
Major Services – Surgical (Class III)
Surgical periodontics,
endodontics, oral surgery
Copays per service
Not covered
Major Services – Restorative (Class IV)
Inlays, onlays, dentures, crowns
Copays per service
Not covered
Child: $2,500 per member
Adult: $2,700 per member
Not covered
Deductible
Network
Preventive & Diagnostic Services (Class I)
Basic Services (Class II)
Fillings, simple extractions,
non-surgical periodontics
Orthodontic Services (Class V)
Please note: Annual benefit maximums apply to some plans. The benefit summary above is
incomplete and does not provide full benefit details.
Not all services and procedures are covered by your benefits contract. This plan summary is for
comparison purposes only and does not create rights not given through the benefit plan.
1
he Dental HMO plan is underwritten by The Dental Network and is an independent licensee
T
of the Blue Cross and Blue Shield Association.
*CareFirst payments are based upon the CareFirst Allowed Benefit. Participating dentists
accept 100% of the CareFirst Allowed Benefits as payment in full for covered services. Nonparticipating dentists may bill the member for any amount over the Allowed Benefit. Providers
are not required to accept CareFirst’s Allowed Benefits on non-covered services. This means
you may have to pay your dentist’s entire billed amount for these non-covered services. At
your dentist’s discretion, they may choose to accept the CareFirst Allowed Benefit, but are not
required to do so. Please talk with your dentist about your cost for any dental services.
If you want more information
on any one of our four
optional dental plans,
including an application, just
mail in the postage-paid card
on the next page.
Consumer Health Insurance Plans 2015
■
Maryland
41
BlueDental Preferred
Preferred Dental Plus
In-Network
In-Network
Out-of-Network Coverage available
Member Pays
Individual Cost Per Day
Less than $1.00
Low Option
$100 Individual/
$300 Family
(applies to
classes I-IV) per
calendar year
Deductible
Network
High Option
$60 Individual/
$180 Family
(applies to classes
II, III, IV) per
calendar year
Less than $1.30
$25 Individual/$75 Family
(applies to classes II, III & IV)
per contract year
Over 4,200 providers in MD, DC, and northern VA. 95,000 dentists nationally.
Preventive & Diagnostic Services (Class I)
Low Option
No charge
after deductible
Basic Services (Class II)
Fillings, simple extractions, non-surgical
periodontics
No charge
20% of Allowed Benefit*
after deductible
20% of Allowed Benefit* after deductible
20% of Allowed Benefit*
after deductible
20% of Allowed Benefit* after deductible
& 12 month benefit waiting period
50% of Allowed Benefit* after deductible
50% of Allowed Benefit* after deductible
& 12 month benefit waiting period
50% of Allowed Benefit* (no deductible)
when medically necessary
50% of Allowed Benefit* after 12 month
benefit waiting period
Major Services – Surgical (Class III)
Surgical periodontics,
endodontics, oral surgery
Major Services – Restorative (Class IV)
Inlays, onlays, dentures, crowns
High Option
No charge
Orthodontic Services (Class V)
Please note: Annual Benefit maximums apply to some plans. The benefit summary above is
incomplete and does not provide full benefit details.
Not all services and procedures are covered by your benefits contract. This plan summary is for
comparison purposes only and does not create rights not given through the benefit plan.
*CareFirst payments are based upon the CareFirst Allowed Benefit. Participating dentists accept
100% of the CareFirst Allowed Benefits as payment in full for covered services. Non-participating
dentists may bill the member for any amount over the Allowed Benefit. Providers are not required
to accept CareFirst’s Allowed Benefits on non-covered services. This means you may have to pay
your dentist’s entire billed amount for these non-covered services. At your dentist’s discretion, they
may choose to accept the CareFirst Allowed Benefit, but are not required to do so. Please talk with
your dentist about your cost for any dental services.
If you’d like to talk to a Product Specialist,
please call 800-544-8703.
42
Consumer Health Insurance Plans 2015
■
Maryland
If you want more information
on any one of our four
optional dental plans,
including an application, just
mail in the postage-paid card
on the next page.
Mail this card for free information
YES, please rush me more information about the
plan(s) that I’ve checked below. I understand
this information is free and I am under
no obligation.
Dental Plan Options
BlueDental Preferred
Dental HMO
Preferred Dental
U65DEN2014
Preferred Dental Plus
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
The CareFirst BlueCross BlueShield
family of health care plans
Additional information
Our commitment
to you
CareFirst’s privacy practices
The following statement applies to CareFirst of
Maryland, Inc. and Group Hospitalization and Medical
Services, Inc. doing business as CareFirst BlueCross
BlueShield, and to CareFirst BlueChoice, Inc., and their
affiliates (collectively, CareFirst).
When you apply for any type of insurance, you disclose
information about yourself and/or members of your
family. The collection, use and disclosure of this
information are regulated by law. Safeguarding your
personal information is something that we take very
seriously at CareFirst. CareFirst is providing this notice
to inform you of what we do with the information you
provide to us.
Categories of personal information we
may collect
We may collect personal, financial and medical
information about you from various sources, including:
■■ Information you provide on applications or
other forms, such as your name, address,
social security number, salary, age and gender.
■■ Information pertaining to your relationship
with CareFirst, its affiliates or others, such as
your policy coverage, premiums and claims
payment history.
■■ Information (as described in preceding
paragraphs) that we obtain from any of
our affiliates.
■■ Information we receive about you from other
sources, such as your employer, your provider
and other third parties.
How your information is used
We use the information we collect about you in
connection with underwriting or administration of an
insurance policy or claim or for other purposes allowed
by law. At no time do we disclose your personal,
financial and medical information to anyone outside of
CareFirst unless we have proper authorization from you
or we are permitted or required to do so by law. We
maintain physical, electronic and procedural safeguards
in accordance with federal and state standards that
protect your information.
In addition, we limit access to your personal, financial
and medical information to those CareFirst employees,
brokers, benefit plan administrators, consultants,
business partners, providers and agents who need to
know this information to conduct CareFirst business or
to provide products or services to you.
Disclosure of your information
In order to protect your privacy, affiliated and
nonaffiliated third parties of CareFirst are subject to strict
confidentiality laws. Affiliated entities are companies
that are a part of the CareFirst corporate family and
include health maintenance organizations, third party
administrators, health insurers, long‑term care insurers
and insurance agencies. In certain situations related to
our insurance transactions involving you, we disclose
your personal, financial and medical information to
a nonaffiliated third party that assists us in providing
services to you. When we disclose information to these
critical business partners, we require these business
partners to agree to safeguard your personal, financial
and medical information and to use the information only
for the intended purpose, and to abide by the applicable
law. The information CareFirst provides to these business
partners can only be used to provide services we have
asked them to perform for us or for you and/or your
benefit plan.
Changes in our Privacy Policy
CareFirst periodically reviews its policies and reserves
the right to change them. If we change the substance of
our privacy policy, we will continue our commitment to
keep your personal, financial and medical information
secure – it is our highest priority. Even if you are no
longer a CareFirst customer, our privacy policy will
continue to apply to your records. You can always review
our current privacy policy online at www.carefirst.com.
Consumer Health Insurance Plans 2015
■
Maryland
45
Rights and responsibilities
Notice of Privacy Practices
CareFirst BlueCross BlueShield and CareFirst BlueChoice,
Inc. (CareFirst) are committed to keeping the confidential
information of members private. Under the Health
Insurance Portability and Accountability Act of 1996
(HIPAA), we are required to send our Notice of Privacy
Practices to members. This notice outlines the uses and
disclosures of protected health information, the individual’s
rights and CareFirst’s responsibility for protecting the
member’s health information.
To obtain an additional copy of our Notice of Privacy
Practices, go to www.carefirst.com and click on
Legal Mandates at the bottom of the page, click on
Patient Rights & Responsibilities then click on Members
Privacy Policy.
Member satisfaction
CareFirst wants to hear your concerns and/or complaints
so that they may be resolved. We have procedures that
address medical and non-medical issues. If a situation
should occur for which there is any question or difficulty,
here’s what you can do:
■■ If your comment or concern is regarding the quality
of service received from a CareFirst representative
or related to administrative problems (e.g.,
enrollment, claims, bills, etc.) you should contact
Member Services. If you send your comments to us
in writing, please include your member ID number
and provide us with as much detail as possible
regarding any events. Please include your daytime
telephone number so that we may contact you
directly if we need additional information.
■■ If your concern or complaint is about the quality of
care or quality of service received from a specific
provider, contact Member Services. A representative
will record your concerns and may request a written
summary of the issues. To write to us directly with a
quality of care or service concern, you can:
Send an email to:
[email protected]
Fax a written complaint to: 301-470-5866
Write to:
CareFirst BlueCross BlueShield/
CareFirst BlueChoice, Inc.
Quality of Care Department,
P.O. Box 17636, Baltimore, MD 21297
46
Consumer Health Insurance Plans 2015
■
Maryland
If you send your comments to us in writing, please include
your identification number and provide us with as much
detail as possible regarding the event or incident. Please
include your daytime telephone number so that we may
contact you directly if we need additional information.
Our Quality of Care Department will investigate your
concerns, share those issues with the provider involved
and request a response. We will then provide you with a
summary of our findings. CareFirst member complaints
are retained in our provider files and are reviewed when
providers are considered for continuing participation
with CareFirst.
If you wish, you may also contact the appropriate
jurisdiction’s regulatory department regarding
your concern:
Maryland
Maryland Insurance Administration
Inquiry and Investigation, Life and Health
200 St. Paul Place, Suite 2700, Baltimore, MD 21202
Phone: 800-492-6116 or 410-468-2244
Office of Health Care Quality
Spring Grove Center, Bland-Bryant Building
55 Wade Avenue, Catonsville, MD 21228
Phone: 410-402-8016 or 877-402-8218
For assistance in resolving a billing or payment
dispute with the health plan or a health care provider,
contact the Health Education and Advocacy Unit of
the Consumer Protection Division of the Office of the
Attorney General at:
Health Education and Advocacy Unit
Consumer Protection Division
Office of the Attorney General
200 St. Paul Place, 16th Floor, Baltimore, MD 21202
Phone: 410-528-1840 or 877-261-8807
Fax: 410-576-6571
web site: www.oag.state.md.us
Hearing Impaired
To contact a Member Services representative, please
choose the appropriate hearing impaired assistance
number below, based on the region in which your
coverage originates.
Maryland Relay Program: 800-735-2258 National Capital
Area TTY: 202-479-3546. Please have your Member
Services number ready.
Language Assistance
Interpreter services are available through Member
Services. When calling Member Services, inform the
representative that you need language assistance.
Note: CareFirst appreciates the opportunity to improve
the level of quality of care and services available for you.
As a member, you will not be subject to disenrollment
or otherwise penalized as a result of filing a complaint
or appeal.
Confidentiality of Subscriber/ Member
Information
All health plans and providers must provide information
to members and patients regarding how their
information is protected. You will receive a Notice of
Privacy Practices from CareFirst or your health plan, and
from your providers as well, when you visit their office.
CareFirst has policies and procedures in place to
protect the confidentiality of member information. Your
confidential information includes Protected Health
Information (PHI), whether oral, written or electronic,
and other nonpublic financial information. Because we
are responsible for your insurance coverage, making
sure your claims are paid, and that you can obtain any
important services related to your health care, we are
permitted to use and disclose (give out) your information
for these purposes. Sometimes we are even required by
law to disclose your information in certain situations. You
also have certain rights to your own protected health
information on your behalf.
Our Responsibilities
We are required by law to maintain the privacy of your
PHI, and to have appropriate procedures in place to
do so. In accordance with the federal and state Privacy
laws, we have the right to use and disclose your PHI for
treatment, payment activities and health care operations
as explained in the Notice of Privacy Practices. We
may disclose your protected health information to the
plan sponsor/employer to perform plan administration
function. The Notice is sent to all policy holders
upon enrollment.
Your Rights
You have the following rights regarding your own Protected
Health Information. You have the right to:
■■ Request that we restrict the PHI we use or
disclose about you for payment or health
care operations.
■■ Request that we communicate with you
regarding your information in an alternative
manner or at an alternative location if you
believe that a disclosure of all or part of your
PHI may endanger you.
■■ Inspect and copy your PHI that is contained
in a designated record set including your
medical record.
■■ Request that we amend your information
if you believe that your PHI is incorrect
or incomplete.
■■ An accounting of certain disclosures of your
PHI that are for some reasons other than
treatment, payment, or health care operations.
■■ Give us written authorization to use your
protected health information or to disclose
it to anyone for any purpose not listed in
this notice.
Inquiries and Complaints
If you have a privacy-related inquiry, please contact the
CareFirst Privacy Office at 800-853‑9236 or send an
email to: [email protected].
Members’ Rights and Responsibilities
Statement
Members have the right to:
■■ Be treated with respect and recognition of
their dignity and right to privacy.
■■ Receive information about the health plan, its
services, its practitioners and providers, and
members’ rights and responsibilities.
■■ Participate with practitioners in decision-
making regarding their health care.
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■■ Participate in a candid discussion of
appropriate or medically necessary treatment
options for their conditions, regardless of cost
or benefit coverage.
■■ Make recommendations regarding the
organization’s members’ rights and
responsibilities.
■■ Voice complaints or appeals about the health
plan or the care provided.
Members have a responsibility to:
■■ Provide, to the extent possible, information
that the health plan and its practitioners and
providers need in order to care for them.
■■ Understand their health problems and
participate in developing mutually agreed
upon treatment goals to the degree possible.
■■ Follow the plans and instructions for care that
they have agreed on with their practitioners.
■■ Pay copayments or coinsurance at the time
of service.
■■ Be on time for appointments and to notify
practitioners/providers when an appointment
must be canceled.
Eligible Individuals’ Rights Statement
Wellness and Health Promotion Services
Eligible individuals have a right to:
■■ Receive information about the organization,
including wellness and health promotion
services provided on behalf of the employer
or plan sponsors; organization staff and
staff qualifications; and any contractual
relationships.
■■ Decline participation or disenroll from wellness
and health promotion services offered by the
organization.
■■ Be treated courteously and respectfully by the
organization’s staff.
■■ Communicate complaints to the organization
and receive instructions on how to use
the complaint process that includes the
organization’s standards of timeliness for
responding to and resolving complaints and
quality issues.
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Compensation and
premium disclosure statement
Our compensation to providers who offer health care
services and behavioral health care services to our
insured members or enrollees may be based on a
variety of payment mechanisms such as fee-for-service
payments, salary, or capitation. Bonuses may be used
with these various types of payment methods.
The following information applies to CareFirst of
Maryland, Inc. and Group Hospitalization and Medical
Services, Inc. doing business as CareFirst BlueCross
BlueShield, and to CareFirst BlueChoice, Inc., and their
affiliates (collectively, CareFirst).
If you desire additional information about our methods
of paying providers, or if you want to know which
method(s) apply to your physician, please call our
Member Services Department at the number listed on
your identification card, or write to:
For plans underwritten by CareFirst BlueChoice, Inc. and
Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield
CareFirst BlueChoice, Inc.
840 First Street, NE
Washingotn, D.C. 20065
Attention: Member Services
For plans underwritten by CareFirst of Maryland, Inc.
CareFirst BlueCross BlueShield
10455 Mill Run Circle
Owings Mills, MD 21117-5559
Attention: Member Services
A. Methods of Paying Physicians
The following definitions explain how insurance carriers
may pay physicians (or other providers) for your health
care services.
The examples show how Dr. Jones, an obstetrician/
gynecologist, would be compensated under each method
of payment.
Salary: A physician (or other provider) is an employee of
the HMO and is paid compensation (monetary wages)
for providing specific health care services.
Since Dr. Jones is an employee of an HMO, she
receives her usual bi-weekly salary regardless of how
many patients she sees or the number of services she
provides. During the months of providing pre-natal
care to Mrs. Smith, who is a member of the HMO, Dr.
Jones’ salary is unchanged. Although Mrs. Smith’s baby
is delivered by Cesarean section, a more complicated
procedure than a vaginal delivery, the method of delivery
will not have an effect upon Dr. Jones’ salary.
Capitation: A physician (or group of physicians) is paid a
fixed amount of money per month by an HMO for each
patient who chooses the physician(s) to be his or her
doctor. Payment is fixed without regard to the volume of
services that an individual patient requires.
Under this type of contractual arrangement, Dr. Jones
participates in an HMO network. She is not employed
by the HMO. Her contract with the HMO stipulates that
she is paid a certain amount each month for patients
who select her as their doctor. Since Mrs. Smith is
a member of the HMO, Dr. Jones monthly payment
does not change as a result of her providing ongoing
care to Mrs. Smith. The capitation amount paid to Dr.
Jones is the same whether or not Mrs. Smith requires
obstetric services.
Fee-for-Service: A physician (or other provider)
charges a fee for each patient visit, medical procedure,
or medical service provided. An HMO pays the entire
fee for physicians it has under contract and an insurer
pays all or part of that fee, depending on the type of
coverage. The patient is expected to pay the remainder.
Dr. Jones’ contract with the insurer or HMO states that
Dr. Jones will be paid a fee for each patient visit and
each service she provides. The amount of payment
Dr. Jones receives will depend upon the number, types,
and complexity of services, and the time she spends
providing services to Mrs. Smith. Because Cesarean
deliveries are more complicated than vaginal deliveries,
Dr. Jones is paid more to deliver Mrs. Smith’s baby than
she would be paid for a vaginal delivery. Mrs. Smith may
be responsible for paying some portion of Dr. Jones’ bill.
Discounted Fee-for-Service: Payment is less than the
rate usually received by the physician (or other provider)
for each patient visit, medical procedure, or service. This
arrangement is the result of an agreement between the
payer, who gets lower costs and the physician (or other
provider), who usually gets an increased volume of patients.
Like fee-for-service, this type of contractual arrangement
involves the insurer or HMO paying Dr. Jones
for each patient visit and each delivery; but under this
arrangement, the rate, agreed upon in advance, is less
than Dr. Jones’ usual fee. Dr. Jones expects that in
exchange for agreeing to accept a reduced rate, she will
serve a certain number of patients. For each procedure
that she performs, Dr. Jones will be paid a discounted
rate by the insurer or HMO.
Bonus: A physician (or other provider) is paid an additional
amount over what he or she is paid under salary,
capitation, fee-for-service, or other type of payment
arrangement. Bonuses may be based on many factors,
including member satisfaction, quality of care, control of
costs and use of services.
An HMO rewards its physician staff or contracted
physicians who have demonstrated higher than average
quality and productivity. Because Dr. Jones has delivered
so many babies and she has been rated highly by her
patients and fellow physicians, Dr. Jones will receive a
monetary award in addition to her usual payment.
Case Rate: The HMO or insurer and the physician (or
other provider) agree in advance that payment will
cover a combination of services provided by both the
physician (or other provider) and the hospital for an
episode of care.
This type of arrangement stipulates how much an insurer
or HMO will pay for a patient’s obstetric services. All
office visits for prenatal and postnatal care, as well as
the delivery, and hospital-related charges are covered
by one fee. Dr. Jones, the hospital, and other providers
(such as an anesthesiologist) will divide payment from
the insurer or HMO for the care provided to Mrs. Smith.
B. Percentage of Provider
Payment Methods
CareFirst BlueChoice, Inc. is a network model HMO and
contracts directly with the primary care and specialty
care providers. According to this type of arrangement,
CareFirst BlueChoice, Inc. reimburses providers primarily
on a discounted fee-for-service payment method. The
provider payment method percentages for CareFirst
BlueChoice, Inc. are approximately 99% discounted feefor-service with less than 1% capitated.
For its Indemnity and Preferred Provider Organization
(PPO) plans, CareFirst of Maryland, Inc. and CareFirst
BlueCross BlueShield contract directly with physicians.
All physicians are Reimbursed on a discounted fee-forservice basis.
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C. Distribution of Premium Dollars
The bar graph below illustrates the proportion of every
$100 in premium used by CareFirst to pay physicians
(or other providers) for medical care expenses, and the
proportion used to pay for plan administration.
Chart A represents an average for all CareFirst
BlueChoice, Inc. HMO accounts based on our annual
statement. The ratio of direct medical care expenses
to plan administration will vary by account.
Chart B represents an average for all CareFirst of
Maryland, Inc. indemnity accounts based on our annual
statement. The ration of direct medical care expenses
to plan administration will vary by account.
Chart C represents an average for all Group
Hospitalization and Medical Services, Inc. indemnity
accounts based on our annual statement. The ration of
direct medical care expenses to plan administration will
vary by account.
Chart A: BlueChoice, Inc.
100%
80%
82%
60%
40%
20%
0%
18%
Medical
Plan Administration
Chart B: CareFirst of Maryland, Inc.
100%
80%
86%
60%
40%
20%
0%
14%
Medical
Plan Administration
Chart C: Group Hospitalization and Medical Services, Inc.
100%
80%
90%
60%
40%
20%
0%
10%
Medical
Plan Administration
Experimental/investigational services
Experimental/Investigational means services that are not recognized as efficacious as that term is defined in the
edition of the Institute of Medicine Report on Assessing Medical Technologies that is current when the care is
rendered. Experimental/Investigational services do not include Controlled Clinical Trials.
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Policy Form Numbers:
CAT: MD/CFBC/CAT/IEA (1/14); MD/CFBC/DOL APPEAL (R.
9/11); MD/CFBC/EXC/HMO/DOCS (1/14); MD/CFBC/EXC/HMO/
YA SOB (1/15); MD/CFBC/DB/HMO/INCENT (1/15) and any
amendments
BluePreferred HSA Bronze $3,500: MD/CF/BP/IEA (1/14); MD/
GHMSI/DOL APPEAL (R. 9/11); MD/CF/EXC/BP/DOCS (1/14);
MD/CF/EXC/BP/BRZ SOB (1/15); MD/CF/DB/PPO/INCENT
(1/15); CFMI/BP/IEA (1/14); CFMI/DOL APPEAL (R. 9/11);
CFMI/EXC/BP/DOCS (1/14); CFMI/EXC/BP/BRZ SOB (1/15);
CFMI/DB/PPO/INCENT (1/15) and any amendments
BlueChoice HSA Bronze $4,000: MD/CFBC/HMO/IEA (1/14);
MD/CFBC/DOL APPEAL (R. 9/11); MD/CFBC/EXC/HMO/DOCS
(1/14); MD/CFBC/EXC/HMO HSA/4000 BRZ SOB (1/15); MD/
CFBC/DB/HMO/INCENT (1/15) and any amendments
BlueChoice Plus Bronze $5,500: MD/CFBC/BC+ IN/IEA (1/14);
MD/CFBC/DOL APPEAL (R. 9/11); MD/CFBC/EXC/BC+ IN/DOCS
(1/14); MD/CFBC/EXC/BC+ IN/BRZ SOB (1/15); MD/CFBC/
DB/POS IN/INCENT (1/15); MD/CF/BC+ OON/IEA (1/14); MD/
GHMSI/DOL APPEAL (R. 9/11); MD/CF/BC+ OON/DOCS (1/14);
MD/CF/EXC/BC+ OON/BRZ SOB (1/15); CFMI/BC+ OON/IEA
(1/14); CFMI/DOL APPEAL (R. 9/11); MD/CF/EXC/BC+ OON/
DOCS (1/14); CFMI/EXC/BC+ OON/BRZ SOB (1/15) and any
amendments
BlueChoice HSA Bronze $6,000: MD/CFBC/HMO/IEA (1/14);
MD/CFBC/DOL APPEAL (R. 9/11); MD/CFBC/EXC/HMO/DOCS
(1/14); MD/CFBC/EXC/HMO HSA/6000 BRZ SOB (1/15); MD/
CFBC/DB/HMO/INCENT (1/15) and any amendments
BlueChoice HSA Silver $1,300: MD/CFBC/HMO/IEA (1/14);
MD/CFBC/DOL APPEAL (R. 9/11); MD/CFBC/EXC/HMO/DOCS
(1/14); MD/CFBC/EXC/HMO HSA/SIL SOB (1/15); MD/CFBC/
DB/HMO/INCENT (1/15) and any amendments
BluePreferred HSA Silver $1,500: MD/CF/BP/IEA (1/14); MD/
GHMSI/DOL APPEAL (R. 9/11); MD/CF/EXC/BP/DOCS (1/14);
MD/CF/EXC/BP/ SIL SOB (1/15); MD/CF/DB/PPO/INCENT
(1/15); CFMI/BP/IEA (1/14); CFMI/DOL APPEAL (R. 9/11);
CFMI/EXC/BP/DOCS (1/14); CFMI/EXC/BP/SIL SOB (1/15);
CFMI/DB/PPO/INCENT (1/15) and any amendments
BlueChoice Silver $2,000: MD/CFBC/HMO/IEA (1/14); MD/
CFBC/DOL APPEAL (R. 9/11); MD/CFBC/EXC/HMO/DOCS
(1/14); MD/CFBC/EXC/HMO/SIL SOB (1/15); MD/CFBC/DB/
HMO/INCENT (1/15) and any amendments
BlueChoice Plus Silver $2,500: MD/CFBC/BC+ IN/IEA (1/14);
MD/CFBC/DOL APPEAL (R. 9/11); MD/CFBC/EXC/BC+ IN/DOCS
(1/14); MD/CFBC/EXC/BC+ IN/SIL SOB (1/15); MD/CFBC/
DB/POS IN/INCENT (1/15); MD/CF/BC+ OON/IEA (1/14); MD/
GHMSI/DOL APPEAL (R. 9/11); MD/CF/EXC/BC+ OON/DOCS
(1/14); MD/CF/EXC/BC+ OON/SIL SOB (1/15); CFMI/EXC/BC+
OON/IEA (1/14); CFMI/DOL APPEAL (R.9/11); CFMI/EXC/BC+
OON/DOCS (1/14); CFMI/EXC/BC+ OON/SIL SOB (1/15) and
any amendments
BlueChoice Gold $0: MD/CFBC/HMO/IEA (1/14); MD/CFBC/
DOL APPEAL (R. 9/11); MD/CFBC/EXC/HMO/DOCS (1/14); MD/
CFBC/EXC/HMO/GOLD 0 SOB (1/15); MD/CFBC/DB/HMO/
INCENT (1/15) and any amendments
BluePreferred Gold $500: MD/CF/BP/IEA (1/14); MD/GHMSI/
DOL APPEAL (R. 9/11); MD/CF/EXC/BP/DOCS (1/14); MD/CF/
EXC/BP/GOLD SOB (1/15); MD/CF/DB/PPO/INCENT (1/15);
CFMI/BP/IEA (1/14); CFMI/DOL APPEAL (R. 9/11); CFMI/EXC/
BP/DOCS (1/14); CFMI/EXC/BP/GOLD SOB (1/15); CFMI/DB/
PPO/INCENT (1/15) and any amendments
BlueChoice Gold $1,000: MD/CFBC/HMO/IEA (1/14); MD/
CFBC/DOL APPEAL (R. 9/11); MD/CFBC/EXC/HMO/DOCS
(1/14); MD/CFBC/EXC/HMO/GOLD 1000 SOB (1/15); MD/
CFBC/DB/HMO/INCENT (1/15) and any amendments
HealthyBlue Gold $1,500: MD/CFBC/HB IN/IEA (1/14); MD/
CFBC/DOL APPEAL (R. 9/11); MD/CFBC/EXC/HB IN/DOCS
(1/14); MD/CFBC/EXC/HB IN/GOLD SOB (1/15); MD/CFBC/
DB/POS IN/INCENT (1/15); MD/CF/HB OON/IEA (1/14); MD/
GHMSI/DOL APPEAL (R. 9/11); MD/CF/EXC/HB OON/DOCS
(1/14); MD/CF/EXC/HB OON/GOLD SOB (1/15); CFMI/HB OON/
IEA (1/14); CFMI/DOL APPEAL (R. 9/11); CFMI/EXC/HB OON/
DOCS (1/14); CFMI/EXC/HB OON/GOLD SOB (1/15) and any
amendments
HealthyBlue Platinum $0: MD/CFBC/HB IN/IEA (1/14); MD/
CFBC/DOL APPEAL (R. 9/11); MD/CFBC/EXC/HB IN/DOCS
(1/14); MD/CFBC/EXC/HB IN/PLAT SOB (1/15); MD/CFBC/
DB/POS IN/INCENT (1/15); MD/CF/HB OON/IEA (1/14); MD/
GHMSI/DOL APPEAL (R. 9/11); MD/CF/EXC/HB OON/DOCS
(1/14); MD/CF/EXC/HB OON/PLAT SOB (1/15); CFMI/HB OON/
IEA (1/14); CFMI/DOL APPEAL (R. 9/11); CFMI/EXC/HB OON/
DOCS (1/14); CFMI/EXC/HB OON/PLAT SOB (1/15) and any
amendments
BluePreferred Platinum $0: MD/CF/BP/IEA (1/14); MD/GHMSI/
DOL APPEAL (R. 9/11); MD/CF/EXC/BP/DOCS (1/14); MD/CF/
EXC/BP/PLAT SOB (1/15); MD/CF/DB/PPO/INCENT (1/15);
CFMI/BP/IEA (1/14); CFMI/DOL APPEAL (R. 9/11); CFMI/EXC/
BP/DOCS (1/14); CFMI/EXC/BP/PLAT SOB (1/15); CFMI/DB/
PPO/INCENT (1/15) and any amendments
BlueDental Preferred HIGH OPTION: CFMI/DEN/IEA (1/14);
CFMI/DB/PREF DENT DOCS-SOB (R. 1/15); CFMI/DB/2015
DENTAL AMEND (1/15); MD/CF/DEN/IEA (1/14); MD/CF/DB/
PREF DENT DOCS-SOB (R. 1/15); MD/CF/DB/2015 DENTAL
AMEND (1/15) and any amendments
BlueDental Preferred LOW OPTION: CFMI/DEN/IEA (1/14);
CFMI/DB/PREF DENT DOCS-SOB LOW (1/15): CFMI/DB/2015
DENTAL AMEND (1/15); MD/CF/DEN/IEA (1/14); MD/CF/DB/
PREF DENT DOCS-SOB LOW (1/15); MD/CF/DB/2015 DENTAL
AMEND (1/15) and any amendments
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. do not discriminate on the basis of race, color, national origin, disability, age,
sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations.
CDS1131-1P (11/14)
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CareFirst BlueCross BlueShield
CareFirst BlueChoice, Inc.
10455 Mill Run Circle
Owings Mills, MD 21117-5559
www.carefirst.com
CO N N E C T W ITH U S :
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
CDS1128-1P (10/14)