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BlueChoice HIPAANorthern Virginia
Welcome to a healthy relationship. One where everyone is committed to keeping you healthy.
take steps to live well, exercise regularly and eat well. And see your
primary care doctor early enough to catch problems when they are most treatable.
, who knows you best, understands how to keep you well and,
if you get sick, can get you back on the road to good health.
—there when you need us most. And there every day encouraging
a healthy lifestyle and an active relationship with your primary care doctor.
BlueChoice HIPAA — Northern Virginia 1
As a member you’ll receive health care services from a regional
network of physicians, specialists and hospitals, and receive a
wide range of benefits including:
n A preventive care package at no charge to you to keep you
healthy, including well child care, immunizations, annual routine
exams, mammograms, PAP tests and prostate screenings.
n No medical deductible to meet —start using your benefits
right away!
n Predictable copays for primary ($20) and specialist ($30)
office visits.
n 365 days of hospitalization for one facility copay per admission,
then inpatient medical and surgical services are covered in full.
n Access to a regional network of over 26,000 participating
doctors, specialists and 60 hospitals throughout Maryland,
the District of Columbia and Northern Virginia. You can visit
doctors where you live and work.
n Around the clock advice with a 24-hour per day, 7-day a week
health care advice line, staffed by registered nurses.
n Vision care benefits and special savings.
n Optional dental benefits.
n Guest Membership in a local Blue Cross Blue Shield Plan
HMO if you or your dependents are away from home at least
90 days. Perfect for extended out-of-town business or travel,
semesters at school or families living apart.
We are pleased to offer you enrollment in our BlueChoice Health Maintenance Organization (HMO) plan offered by CareFirst BlueChoice, Inc. Designed for today’s health conscious and busy families, BlueChoice HIPAA offers one less thing to worry about during your hectic day.
Welcome
2 BlueChoice HIPAA — Northern Virginia
What is HIPAA?
In 1996, the Health Insurance Portability and Accountability
Act (HIPAA) became federal law. This ground-breaking
health insurance act allows you to maintain insurance
coverage when you leave a group insurance plan.
After you leave a group plan, you will receive a “Certificate
of Creditable Coverage,” which lists the amount of time you
were in a policyholder health insurance plan. This can be used
to eliminate the need for completing a medical questionnaire
and reduce a pre-existing waiting period (which could be up
to 12 months) when applying for individual coverage.
Applying for CoverageTo enroll in HIPAA coverage you must submit a completed
application and Certificate of Creditable Coverage. You
and your covered dependents may enroll if all of the
following criteria are met:
n You have 18 months or more of creditable coverage
with the most recent coverage under individual health
insurance coverage, or group employer-sponsored plan,
governmental plan, church plan, State Children’s Health
Insurance Plan (S-CHIP), or a health benefit plan offered
in conjunction with any of these plans. Certificates of
Creditable Coverage must indicate at least 18 months
of aggregate health insurance coverage.
n You have elected and exhausted health insurance
benefits through a COBRA or similar group, state
or federal continuation plan, including the Federal
Employee Health Benefits Program (FEHBP), FEHBP
Temporary Continuation of Coverage (TCC) or state
continuation coverage, if available.
n You must have no more than a 63-day break in
coverage.
n You must not be eligible for Medicare A or B, Medicaid,
or any other employer-sponsored plan.
n You must not be covered by any other health insurance
plan.
n You must not have had prior insurance coverage
terminated because of the applicant’s failure to
pay the required premium or fraudulent/intentional
misrepresentations made by the applicant.
If you do not qualify for HIPAA coverage at this time,
please call our Product Specialist at (800) 544-8703.
They can assist you with finding a comparable medically
underwritten plan that may be available to you.
BlueChoice HIPAA — Northern Virginia 3
Your Health Care TeamYour PCP oversees your routine and preventive care,
administers your prescriptions, becomes familiar with your
medical history and works closely with you to help make
your medical decisions. When specialized care is needed,
your PCP will recommend a specialist within the CareFirst
BlueChoice network.
Choose a PCPRefer to the enclosed provider directory to choose your PCP.
For the most up-to-date listing, the CareFirst BlueChoice
provider directory is available and updated every 15 days
at www.carefirst.com/doctor. You may also call your doctor
to see if he or she participates.
Preventive CareBlueChoice HIPAA aims to keep you healthy – emphasizing
prevention, early detection and early treatment. We work with
you to help prevent illness by offering you preventive care,
office visits and screenings at no charge. We encourage you to
seek care when it is first needed, rather than waiting.
Well-Child CareBlueChoice HIPAA wants to start your children on the
road to good health with coverage for all childhood
immunizations and checkups. We encourage parents to
take advantage of this most important service.
Women’s Health / Men’s HealthBlueChoice HIPAA provides women’s and men’s preventive
health coverage such as routine mammograms and
prostate screenings and PAP tests – all at no charge to you.
And women do not need a referral for gynecological care as
long as care is provided by a CareFirst BlueChoice OB/GYN.
HospitalizationDon’t worry. If you receive care through your PCP, you
are covered. We’ll take care of you with hospitalization,
including all physician charges for covered services, for
one facility copay per admission.
No Hassle BillingYou pay no medical deductible and just a predictable, per
visit copayment. In addition, BlueChoice HIPAA provides
direct reimbursement to your doctor, which means no
claims to file.
Discount Drug ProgramAs a BlueChoice HIPAA member, you will receive valuable
discounts on prescription drugs at over 62,000 pharmacies
nationwide – for free! With this program, members are
guaranteed the lowest price available in that pharmacy at
the time of purchase. There is no additional cost to you to
take advantage of this value-added program.
You and your family members each choose a Primary Care Physician (PCP) from the CareFirst BlueChoice regional network to coordinate all of your health care needs.
How the Plan Works
4 BlueChoice HIPAA — Northern Virginia
Summary of Benefits
* “Child” means your eligible child up to age 26. Eligibility requirements are defined in the contract.** “Adult” means the Spouse or Domestic Partner of the Policyholder who satisfies the eligibility requirements defined in the contract.
Services You PayGeneral InforMatIon
Member Deductible $0
Out-of-Pocket MaximumIndividualIndividual & Child(ren)*/Individual & Adult**Family
$3,600$7,200$7,200
lIfetIMe MaxIMuM No lifetime maximum
PreventIve ServICeS and offICe vISItS
Well-Child – Exams & Immunizations (up through age 17) No charge for office visits and screenings
Adult Routine Preventive Health No charge for office visits and screenings
Routine Gynecological Visits (No charge for PAP Smear) No charge for office visits and screenings
Prostate Screening Visits (No charge for PSA test) No charge for office visits and screenings
Colorectal Cancer Screening Test No charge for office visits and screenings
Mammography Screenings No charge for office visits and screenings
Allergy Testing and Treatment $20 copay PCP/$30 copay Specialist
Annual Routine Eye Exam (at participating Davis Vision provider) (optometrists and ophthalmologist)
$10 copay at a plan designated vision care center$30 copay in a plan providers office
Hearing Screening $20 copay PCP/$30 copay Specialist
outPatIent MedICal and SurGICal ServICeS
Physician Office Visit for Illness $20 copay PCP/$30 copay Specialist
Rehabilitative Services (Physical, Occupational and Speech Therapy; each limited to 30 visits per illness or injury per calendar year)
$20 copay PCP/$30 copay Specialist
Mental Health Coverage (visits 1-20) $10 copay per visit
Surgical Services – Professional $20 copay PCP/$30 copay Specialist
Surgical Services – Hospital or Other Facility $50 facility copayment plus $20 copay PCP/$30 copay Specialist copayment
Diagnostic Procedures $20 copay PCP/$30 copay Specialist
X-rays and Lab Tests at Plan Facilities No charge
InPatIent HoSPItal ServICeS
365 Days Room and Board (Semi-Private Room) $700 facility copay per admission
Medical and Surgical Services No charge
Prescription Drugs (Inpatient) No charge
MaternItY ServICeS
Prenatal and Postnatal CarePCPSpecialist
$20 copay per visit (up to $200 per pregnancy)$30 copay per visit (up to $300 per pregnancy)
Hospital Facility $700 facility copay per admission
Birthing Center $30 copay per visit
Nursery Care (for newborns) No charge
eMerGenCY or urGent Care
Ambulance (when medically necessary) No charge
Plan-Affiliated Urgent Care Facility $30 copay
Hospital Emergency Room or Non-Plan Urgent Care Facility (waived if admitted) $50 copay
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
CDSBC Full Page Insert (3/13)
Summary of Benefits & Coverage
As required by the Affordable Care Act, all health insurers will provide potential health plan
participants the following standardized forms:
� A Summary of Benefits and Coverage (SBC) summarizing the key features of the plan.
� A Uniform Glossary of Coverage and Medical Terms commonly used in health
insurance coverage.
To view these documents, please visit www.carefirst.com/individual. Once you enter your zip
code, gender and date of birth, you will be directed to a quoting page where you can view
and compare plans. Look for the Summary of Benefits & Coverage link for each plan by
clicking on the plan name and scrolling to the bottom of the webpage.
If you have any questions, please call your broker or one of our Product Consultants at
(410) 356-8000 or toll-free at (800) 544-8703 Monday-Friday, 8 a.m. – 8 p.m.
BlueChoice HIPAA — Northern Virginia 5
Dental Discounts (Included)
Regular preventive dental care is an important part of
staying healthy.
That’s why CareFirst BlueChoice members have access to a
regional network of dentists (including specialists, where
available) who provide discounts of between 20% and
40% on virtually all types of dental procedures, including
routine office visits, X-rays, exams, fillings, root canals
and even orthodontics.
The BlueChoice Discount Dental program is included at
no additional charge as part of your CareFirst BlueChoice
medical plan and is administered by The Dental Network,
an independent licensee of the Blue Cross and Blue Shield
Association.
CareFirst BlueChoice members need only show their
CareFirst BlueChoice identification card when visiting any
participating plan provider to receive dental services at
discounted fees. Because the Discount Dental program is
not insurance, there are no claim forms, no maximums and
no deductibles.
Upgraded Dental (Optional)We offer three upgraded dental options in the Individual
Select product family: dental HMo, Preferred dental, and
Preferred dental Plus.
dental HMo offers you dental care with lower, predictable
copayments for routine and major dental services such as
preventive and diagnostic dental care, surgical extractions,
root canal therapy and orthodontic treatment. As a
member of our Dental Health Maintenance Organization
(Dental HMO) plan, you’ll select a general dentist from
a network of 580+ participating providers to coordinate
all of your dental care needs. When specialized care is
needed, your general dentist will recommend a specialist
within the Dental HMO network.
Preferred dental offers a larger dental network of
over 4,000 participating providers, 100% coverage for
preventive and diagnostic dental care, and potential in-
network savings for major procedures. And, there are no
deductibles to meet.
Preferred dental Plus provides coverage for an extensive
range of basic and major dental services, including no
charge oral exams, cleanings and X-rays when you visit
network providers. With Preferred Dental Plus, you can
choose from more than 3,600 network general dentists
and specialists and have access to a national dental
network which includes 74,000 dental providers across
the country.
All of our Individual Select dental plans are guaranteed
acceptance and require no claim forms when you stay in-
network.
If you have questions regarding dental coverage,
participating providers, or wish to request an application,
please contact a Product Specialist at (800) 544 8703.
Vision (Included)
Eye care benefits are part of your medical plan, through our
network administrator, Davis Vision*. For annual routine
eye examinations, just call and make an appointment with
one of the participating providers, and pay the $10 copay
at the time of service. Additionally, through Davis Vision,
you receive discounts of approximately 30% on eyeglass
lenses and frames or contact lenses.
To locate a vision provider, contact Davis Vision at
(800) 783-5602 or visit www.carefirst.com/doctor.
* An independent company that does not provide CareFirst BlueCross
BlueShield products or services. The company is solely responsible for its
products, services and/or discounts mentioned herein.
Dental and Vision
6 BlueChoice HIPAA — Northern Virginia
options / Blue365 discount ProgramsAs a member, you have access to discounts on fitness
centers, acupuncture, spas, massages, chiropractic care,
nutritional counseling, laser vision correction, and more! Visit
www.carefirst.com/options to learn more.
nurse line – firstHelp™Any time, day or night you can speak with a nurse. Registered
nurses are available to answer your health care questions
and help guide you to the most appropriate care. Simply call
(800) 535-9700 and a registered nurse will ask about your
symptoms and help you decide on the best source of care.
My Care first WebsiteTake an active role in managing your health and visit My
Care First at www.carefirst.com/mycarefirst. Find nearly
300 interactive health related tools, a multi-media section
with more than 400 podcasts, and recipes you can search
by food group or dietary restrictions. Plus, there are videos
and tutorials on chronic diseases and an encyclopedia with
information on more than 3,000 conditions.
As a BlueChoice HIPAA member you are encouraged to take advantage of the Health + Wellness program, at no additional charge. Whether you’re looking for health and wellness tips or support to manage a health condition—you’ll find it with Health + Wellness.
BlueChoice HIPAA — Northern Virginia 7
Pedometer appCount your steps, distance traveled and calories burned
for each workout with the CareFirst Ready, Step, Go! app.
Aim for 10,000 steps a day to help control your weight,
reduce stress, strengthen your heart and lungs, and
improve bone density. This free app is available to anyone
who has an iPhone, iPod Touch or Droid smartphone. To
download it, visit your favorite app store and search for
“Ready, Step, Go!”
Vitality MagazineOur member magazine has tools to help you achieve a
healthier lifestyle. Vitality provides you with updates to
your health care plan, a variety of health and wellness
topics, including food and nutrition, physical fitness and
preventive health. As a member, you will receive Vitality
magazine three times per year.
Health newsSign up for our monthly electronic member newsletter
to receive health-related articles and recipes via email.
Visit www.carefirst.com/healthnews to subscribe to
information about:
n Making healthy choices.
n Adding physical activity to your day.
n Preparing nutritious and delicious recipes.
n Getting the best health care.
n Managing chronic conditions.
telephonic Health CoachingThe Telephonic Health Coaching program is designed
to help you build confidence as you learn new skills and
positive lifestyle behaviors. You can interact with your
coach through a private, secure Web-based message board
and by phone. You and your coach will work together to
develop a personalized plan with milestones for achieving
goals. Your coach will monitor your progress and provide
guidance and support as needed.
Once you complete your health risk assessment, you’ll
receive an email with details on accessing online health
coaching programs.
online Health CoachingTo help you meet your health goals, take advantage of our
confidential Web-based health coaching program to help
you improve in the following areas:
n Weight management
n Stress management
n Smoking cessation
n Physical activity
n Overcoming depression
n Care for your back
Health advisingAfter you complete the Health Assessment, a health
advisor may contact you. The health advisor can answer
your questions and discuss your results. The Health
Advising session is usually 10-15 minutes long.
(continued)
8 BlueChoice HIPAA — Northern Virginia
Applying for a BlueChoice HIPAA plan is easy. Select one of the three ways to apply from the list below.
Three ways to apply!Applying for BlueChoice HIPAA is easy. To be eligible each
family member applying must be a resident of Northern
Virginia and live in the city of Alexandria or Fairfax, the town
of Vienna, Arlington County, or the areas of Fairfax and Prince
William counties lying east of Route 123.
1. Apply online and be approved in as little as 24 hours at
www.carefirst.com/individual, or
2. Fill out and mail the enclosed application. Send no
money when you apply. We’ll begin processing your
application right away, or
3. Apply through your broker.
PleaSe note: Certificates of Creditable Coverage must
accompany your application for each HIPAA-eligible individual.
You must request Certificates from your former employer. If
these Certificates are not included with your application, you
will be denied coverage in CareFirst BlueChoice HIPAA.
If you choose to apply online you will need to fax your Certificate
of Creditable Coverage to (800) 305-1351. You may also call
one of our Product Specialists at (410) 356-8000 or toll free at
(800) 544-8703 who will assist you with that process.
Apply Today for BlueChoice HIPAA
Pay Your Premium Online with eBilling!as a member you can save time and take advantage of our online billing system called eBilling.
With eBilling, you can:
n Set up recurring monthly payments with your debit, checking or credit card account.
n view and pay your monthly bill online 24 hours a day, 7 days a week.
n Check the status of your payment and any outstanding balances.
You can set up your eBilling account on your application or through My Account located at www.carefirst.com/myaccount.
BlueChoice HIPAA — Northern Virginia 9
Apply Today for BlueChoice HIPAA (continued)
Steps to apply.1. review the plan benefits and premiums. The enclosed rate chart, which indicates coverage type
and age, shows your monthly premium.
2. Choose a coverage type. Select from:
n Individual
n Individual and Child(ren)*
n Individual and Adult **
n Family (two eligible adults and eligible dependents)
* “Child” means your eligible child up to age 26. Eligibility
requirements are defined in the contract.
** “Adult” means the Spouse or Domestic Partner of the
Policyholder who satisfies the eligibility requirements defined in
the contract.
3. Select a PCP. Select a Primary Care Physician for each family member
and write the doctor’s name and ID number on your
application.
once you have submitted your application, you can call
the application Status Hotline at (877) 746-7515 with
questions. Your coverage will become effective the first
of the month following the month in which we approve
your application.
If you have questions, please call your broker or one of
our Product Specialists at (410) 356-8000 or toll free at
(800) 544-8703, Monday-friday 8 a.m. – 8 p.m. or, visit the
Carefirst website at www.carefirst.com/individual.
10 BlueChoice HIPAA — Northern Virginia
Privacy Practices
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
BlueChoice. CareFirst BlueChoice is providing this notice
to inform you of what we do with the information you
provide to us.
Categories of Personal Information We May CollectWe may collect personal, financial and medical
information about you from various sources, including:
n Information you provide on applications or other forms,
such as your name, address, social security number,
salary, age and gender.
n Information pertaining to your relationship with
CareFirst BlueChoice, its affiliates or others, such as
your policy coverage, premiums and claims payment
history.
n Information (as described in preceding paragraphs)
that we obtain from any of our affiliates.
n Information that we receive about you from other
sources, such as your employer, your provider and other
third parties.
How Your Information Is usedWe 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 BlueChoice
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 BlueChoice
employees, brokers, benef it plan administrators,
consultants, business partners, providers and agents
who need to know this information to conduct CareFirst
BlueChoice business or to provide products or services to
you.
disclosure of Your InformationIn order to protect your privacy, affiliated and nonaffiliated
third parties of CareFirst BlueChoice are subject to strict
confidentiality laws. Affiliated entities are companies that
are a part of the CareFirst BlueChoice 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 BlueChoice 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 PolicyCareFirst BlueChoice 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 BlueChoice customer, our
privacy policy will continue to apply to your records. You
can always review our current privacy policy online at
www.carefirst.com.
BlueChoice HIPAA — Northern Virginia 11
Exclusions and Limitations
Coverage is not provided for:8.1 Services, tests or procedures that are not Medically Necessary.
Although a service is listed as covered, benefits will be provided only if the service is Medically Necessary.
8.2 Experimental or Investigative: treatment; procedure; facility; equipment; drug; drug usage; device or supply.
8.3 The cost of services that: a. Are furnished without charge; or, b. Is normally be furnished without charge to persons without
coverage for health expenses. This exclusion does not apply to services that are covered under a
State Assistance Program.8.4 Services that are not described as covered in this Evidence of Coverage
or that do not meet all other conditions and criteria for coverage, as determined by the Plan. Referral by a Primary Care Physician and/or the provision of services by a Plan Provider does not, by itself, entitle a Member to benefits if the services are non-covered services or do not otherwise meet the conditions and criteria for coverage.
8.5 Any routine foot care related to hygiene or preventive foot care such as: trimming of corns; calluses; flat feet; fallen arches; chronic foot strain; or, partial removal of a nail without the removal of its matrix.
8.6 Routine dental care such as extractions; treatment of cavities; care of the gums or bones supporting the teeth; treatment of periodontal abscess; removal of impacted teeth; orthodontia; false teeth; or, any other dental services or supplies. These services may be covered under a Dental Endorsement purchased by the Subscriber and attached to this Evidence Of Coverage. This exclusion will not be used to deny covered services as described in Part 7.
8.7 Plastic surgery, cosmetic surgery or other services primarily intended to correct, change or improve appearance. Such services are excluded, regardless of the underlying cause of the condition or any expectation that an alteration of appearance may be psychologically or developmentally beneficial. This exclusion will not be used to deny covered services as described in Part 7.
8.8 Treatment rendered by a health care provider who is a member of the Member’s family (parents, spouse, brothers, sisters, children).
8.9 Prescription and non-prescription drugs routinely obtained and self-administered by the Member for outpatient use; unless the prescription drug is specifically covered under this Evidence Of Coverage or a Prescription Drug Rider when such Endorsement is attached to this Evidence Of Coverage.
8.10 Artificial aids and corrective appliances, such as: braces; external prosthetic devices; orthopedic devices; hearing aids; corrective lenses; or, eyeglasses.
8.11 Any procedure or treatment related to changing a Member’s sex.8.12 Services to reverse voluntary surgically induced infertility, such as a
reversal of a sterilization.8.13 Infertility treatment including but not limited to: assisted reproductive
technologies such as: in vitro fertilization; GIFT; ZIFT; related evaluative procedures; artificial insemination; and, any drugs, diagnostic services or medical preparation related to the same.
8.14 Fees or charges relating to: fitness programs; weight loss or weight control programs; physical, pulmonary or cardiac conditioning programs; exercise programs; physical conditioning; use of passive or patient-activated exercise equipment; or, self-care or self-help training or education, except covered under Part 7.12.
8.15 Treatment for obesity except in the instance of morbid obesity.8.16 Wigs, except for hair prosthesis as described in Part 7.2.t.8.17 Medical or surgical treatment of myopia or hyperopia. Coverage is not
provided for keratotomy and other forms of refractive keratoplasty, or any complications thereof.
8.18 Services furnished as a result of a referral prohibited by law.8.19 Services solely required or sought on the basis of a court order or as
a condition of parole or probation unless approved by the Medical Director.
8.20 Chiropractic services.8.21 Health education classes and self-help programs, except as approved
by the Plan.8.22 Acupuncture services, except for anesthesia.8.23 Any service related to recreational activities. This includes, but is
not limited to: sports; games; equestrian activities; and, athletic training. These services are not covered even though: they may have therapeutic value; or, be provided by a health care provider.
7.13 durable Medical equipment. b. Benefits are not provided for: 1. A convenience item. Any item that increases physical comfort
without serving a Medically Necessary purpose, such as a bedside table.
2. Environmental control equipment. Any device or appliance that alters or maintains the conditions in the existing surroundings, such as an air conditioning unit.
3. Furniture items. Movable articles or accessories which serve as a place upon which to rest (people or things) or in which things are placed or stored, such as a chair or a dresser.
4. Exercise equipment. Any device or object that serves as a means to allow for energetic physical action or exertion in order to train, strengthen or condition all or part of the human body.
5. Institutional equipment. Any device or appliance that is appropriate for use in a medical facility and is not appropriate for use in the home, such as parallel bars.
7.14 organ/tissue transplants. b. Limitations and Exclusions. 1. All services and charges related to transplanting non-human
organs are excluded. This exclusion will not be used to deny Medically Necessary non-Experimental grafts that are covered under the Evidence Of Coverage.
2. Donor benefits are not provided when the transplant recipient is not a Member.
3. A transplant not listed above is not covered. This excludes coverage for:
a) Complications resulting from any procedure not listed in Part 7.14.a; and,
b) Services or supplies related to any procedure not listed in Part 7.14.a., such as: high dose chemotherapy; radiation therapy; and, any other form of therapy.
12 BlueChoice HIPAA — Northern Virginia
PleaSe note: Experimental / Investigational services
are not covered under this health plan.
Experimental/Investigational means a service or supply
that is in the developmental stage and in the process of
human or animal testing excluding Clinical Trial Patient
Cost Coverage as stated in the Description of Covered
Services. Services or supplies that do not meet all five of
the criteria listed herein are deemed to be Experimental/
Investigational:
A. The Technology* must have final approval from the
appropriate government regulatory bodies;
B. The scientific evidence must permit conclusions
concerning the effect of the Technology on health
outcomes;
C. The Technology must improve the net health outcome;
D. The Technology must be as beneficial as any
established alternatives; and,
E. The improvement must be attainable outside the
Investigational settings.
*Technology includes drugs, devices, processes, systems, or techniques.
Experimental/Investigational Services
BlueChoice HIPAA — Northern Virginia 13 13 BlueChoice HIPAA — Northern Virginia
Medicare Eligible Applicants
1. CareFirst BlueCross BlueShield (CareFirst) and CareFirst
BlueChoice, Inc. (CareFirst BlueChoice) have deter-
mined that the prescription drug coverage offered in the
individual CareFirst BlueChoice, BluePreferred, Personal
Comp and Catastrophic health benefit plans with drug,
on average for all plan participants, is NOT expected to
pay out as much as the new standard Medicare pre-
scription drug coverage. this is important, because for
most people, enrolling in Medicare prescription drug
coverage during the initial eligibility period means you
will get more assistance with drug costs.
2. You have decisions to make about Medicare prescrip-
tion drug coverage that may affect how much you pay
for that coverage, depending on if and when you enroll.
Read this notice carefully - it explains your options.
Consider enrolling in Medicare prescription drug coverage.
The Prescription Drug Coverage you would have with this
Plan is on average for all plan participants, NOT expected
to pay out as much as the standard Medicare prescription
drug coverage will pay. You may want to consider enrolling
in a Medicare Prescription Drug Plan.
Once you reach the end of your initial period of Medicare
eligibility, if you go 63-days or longer without prescription
drug coverage that is at least as good as Medicare’s
prescription drug coverage, your premium for Medicare
Prescription Drug Coverage will go up at least 1% per
month of the national base price for every month that
you did not have prescription coverage that is as good as
the Medicare Prescription Drug Coverage. You will have
to pay this higher premium as long as you have Medicare
prescription drug coverage. For example, if you go
19-months without coverage, your premium will always be
at least 19% higher than what most people pay.
You are eligible to enroll in a Medicare Prescription Drug
Program during your initial period of Medicare eligibility.
After your initial eligibility you can only join a Medicare
Prescription Drug Plan between November 15 and Decem-
ber 31 of any year. This may mean the number of months
you have to wait for coverage will be longer, which could
make your premium higher.
Medi-CareFirst BlueCross BlueShield, a member of the
CareFirst Blue Cross and Blue Shield family of health
plans, offers two Medicare Prescription Drug Plans (for
Maryland, D.C. and Delaware residents only). For informa-
tion on these products please call 1-888-784-0790
(TTY/TDD 1-888-784-0868).
Your Individual Health Plan Coverage through CareFirst
pays for other health expenses, in addition to prescrip-
tion drugs. You would still be eligible to receive health
and prescription drug benefits if you choose to enroll in
a Medicare Prescription Drug Plan and remain in your
individual health plan.
Compare your current coverage, including which drugs
are covered, with the coverage and cost of the plans of-
fering Medicare prescription drug coverage in your area.
For further information please call the Individual Sales
Department at 1-888-784-0790 or (TTY/TDD 1-888-784-
0868), 8:00 am–8:00 pm, 7 days a week. NOTE: You may
receive this notice at other times in the future such as
before the next period you can enroll in Medicare pre-
scription drug coverage, and if this coverage changes. You
also may request a copy.
For people with limited income and resources, extra help
paying for a Medicare Prescription Drug Plan is available.
Information about this extra help is available from the
Social Security Administration (SSA). For more informa-
tion about this extra help, visit SSA online 1-800-772-1213
(TTY/TDD 1-800-325-0778).
This information applies to Medicare Eligible applicants only.Important notice from Carefirst and Carefirst BlueChoice about this Prescription drug Coverage and Medicare
Please read this notice carefully, and keep it where you can find it. This notice has information about the offered prescription drug coverage with CareFirst BlueCross BlueShield and prescription drug coverage available for people with Medicare. It also tells you where to find more information to help you make decisions about your prescription drug coverage.
You can also get more information about Medicare
Prescription drug Plans from these places:
n Visit www.medicare.gov for personalized help
n Call your State Health Insurance Assistance
Program (see your copy of the Medicare & You
handbook for their telephone number)
n Call 1-800-MEDICARE (1-800-633-4227). TTY/TDD
users should call 1-877-486-2048.
CareFirst BlueChoice, Inc. is an independent licensee 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.
840 First Street, NE
Washington, DC 20065
www.carefirst.com
BRC7286-1N (8/12)
Form Numbers:
VA/CC/GC EOC (8/01); VA/CC/GC Schedule (8/01) and any amendments.
Benefits provided under the Agreement are not a grandfathered health benefit
plan under the Patient Protection and Affordable Care Act.