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Summary of Health Insurance Plan The Diocese participates in the CareFirst BlueChoice Opt-Out Plus Open Access plan. This is a dual choice plan consisting of HMO (Primary Care Physicians), PPO (Participating Provider Option), and Out-of-Network provider option. The Open Access feature allows participants the freedom to see specialists without a referral from their Primary Care Physician.
Participants must see participating specialist. A primary care physician must be chosen. Participants may change doctors at anytime. (A provider directory is available on the CareFirst Web site).
Coverage includes benefits for hospital, medical, major medical, dental, vision, mental health and prescription services. Prescription Drug Coverage: Members may choose to fill their prescription through a retail pharmacy or they may choose to fill their prescriptions through our Mail Order Program. The Member is responsible for the Co-payment and any deductibles that must be met. Our plan applies a $50 deductible per year for prescriptions. Once the deductible has been met, prescriptions will be covered under a Three Tier Prescription Drug Program. The 3-Tier Prescription Drug Program is based on the use of a formulary, or list of preferred drugs. These preferred drugs are selected for their efficiency and affordability, and include both generic (Tier 1) and preferred brand name (Tier 2) drugs. (CareFirst sometimes refers to Tier 2 drugs as formulary drugs, but this has nothing to do with their formulation. It simply means that they are on the formulary.) Members may view CareFirst Preferred Drug List by visiting the CareFirst website at: http://notesnet.carefirst.com/formulary/formulary.nsf/vwprintcode/print?Opendocument The plan permits members to purchase non-preferred brand name (Tier 3) drugs, but with a higher co-payment. Giving incentives to people to use the least costly effective drugs can control this area of our claims experience. Retail Pharmacy Services: Members may fill their 30 day prescription at a participating retail pharmacy. Most pharmacies are participating. If the member is unsure if the pharmacy is participates, they may call the AdvancePCS phone number found on the back of their CareFirst insurance card. Drugs taken on a continuous basis should be filled through the Mail order program (see below). Rates are as follows: Per member/per year Deductible: $50.00 Tier 1-Generic Drugs (lowest co-pay): $15.00 Mail Order Services: EFFECTIVE APRIL 1, 2005 THE NEW MAIL ORDER PRESCRIPTION VENDOR IS WALGREENS. Rates are as follows: Per member/per year Deductible: $50.00 Tier 1-Generic Drugs (lowest co-pay): $30.00 Dental Coverage: Dental is covered under four levels. Coverage is based on the UCR (Usual, Customary, and Reasonable) fees. A dental provider does not have to participant with CareFirst. There are some dentists that participate and will accept their UCR fees. Receiving dental care from a preferred dentist could save on out-of-pocket cost. For a list of Preferred dentist in our area please contact the Insurance Administrator . Level I : Preventive and Diagnostic Services - Covered at 100% of UCR No deductable . Level II : Basic Services Covered at 80% UCR, except 50% for Periodontics Deductible applies Level III: Major Services Surgical Covered at 80% UCR, except 50% for Periodontics Deductible applies Level IV : Major Services Restorative - Covered at 50% UCR Deductible applies Level V : Orthodontic Services - Covered at 50% UCR Lifetime maximum benefits for each member is $800 Vision Care: Vision care consists of discounts through participating Davis Vision Care Participating Providers. Member may visit www.davisvision.com and follow links for “Members”. The member ID # is the same as your CareFirst medical ins. ID #. Vision Discounts consists of a $15 co-pay for routine eye exams for glasses;15% off contact lens examinations; $25 copay at participating ophthalmologists; and 20% off frames and lenses.
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