carefirst bluechoice hipaa - northern virginia · root canal therapy and orthodontic treatment. as...

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.


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


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.


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


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.


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)


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.


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.


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.


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.


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.

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