CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. BlueChoice Advantage HSA/HRA Silver 1500 Integrated Deductible Summary of Benefits Services In-Network You Pay1 Out-of-Network You Pay1 ... is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are endobj 19 0 obj CareFirst: 2020 Small Group: POS: BlueChoice Plus HSA/HRA Silver 1500. /Parent 16 0 R • 2021 benefit summaries will be posted on the broker portal soon. 0000018163 00000 n /GS2 25 0 R Deductible: Individual/Family. /OPM 1 /T1_7 45 0 R 0000007796 00000 n BlueChoice Advantage HSA/HRA Combined Rx Summary of Plan Options; Options Features Medical Summary Rx Summary; Option 1: In: $1,400 Ded. /T1_4 31 0 R 0 0 0 0 0 0 519 0 482 611 Services In-Network You Pay1 Out-of-Network You Pay1 HOSPITALIZATION—MEMBERS ARE RESPONSIBLE FOR APPLICABLE PHYSICIAN AND FACILITY FEES Outpatient Facility Surgery (Freestanding Facility) Deductible, then $100 per visit Deductible, then 20% of Allowed Benefit ��C1\dR�Te�Ry��/R�쏰�^U��ێi�TY�MZ��.���N��X"�),t��o�d:x�Z��ʧ#�O6K\�ku�ג[�mF���D 4. bluechoice open access point of service evidence of coverage important notice covered benefits received from an out-of-network provider, except in certain circumstances (see section 5.0. epsilon Bronze: DC Metro In-Network. basis of race, color, national origin, age, disability or sex. 0000003366 00000 n Quoting may begin now for new and renewing 2-50 Maryland non-MSGR groups for January 1, 2012 effective /TrimBox [ 0 0 612 792 ] /SMask /None 0000016054 00000 n BlueChoice Advantage HSA/HRA Integrated Deductible Summary of Benefits Services In-Network You Pay1,2 Out-of-Network You Pay1,3 ... BlueChoice service area, when covered services are rendered by a provider in the preferred provider network, care is also covered at the in-network level. >> Summary of Benefits and Coverage. Benefit changes due to AV. H���Oo�0��| /BleedBox [ 0 0 612 792 ] /O 21 Out-Network: $3,000 / $6,000 Health Reimbursement Agreement. Summary of Benefits and Coverage. BlueChoice Advantage HSA/HRA Bronze 6000. >> Prescription Search. An HRA is a medical spending account that is entirely funded by an employer. BlueChoice HSA Silver 1500 Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO This is only a summary. 0000000012 00000 n There are open access plans through BlueChoice Advantage and BlueChoice Advantage Plus, which allows members to visit doctors and specialists without a referral. /Type /ExtGState /LastChar 121 My Health Toolkit Access your digital ID card, check claims status, view plan details, and check your benefits. “World’s Most Ethical Companies” and “Ethisphere” names and marks are registered trademarks of Ethisphere LLC. Mar 03 SC BlueCross, SC BlueChoice Members Can See a Doctor Without Going to the Doctor's Office Feb 10 BlueCross BlueShield of South Carolina, BlueChoice HealthPlan of South Carolina Start Maternity Blue Distinction Program, Recognize South Carolina Hospitals for … Out: $2,800 Ded. 0000014760 00000 n BlueChoice HMO HSA/HRA $2,000 BlueChoice HMO Referral HSA/HRA $4,000-SE BlueChoice HMO HSA/HRA $3,000 BlueChoice HMO Referral $30/$40 BlueChoice HMO $1,000-SE BlueChoice … delta Silver: Nationwide In-Network. 0000047018 00000 n BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. /BaseFont /IQWVHN+AvenirLTStd-Book 0000036657 00000 n BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. /ArtBox [ 0 0 612 792 ] If you want more detail about your coverage and costs, you can get the complete terms in the policy or sample plan document at www.carefirst.com or by logging into My Account. /SA true /T1_2 29 0 R BlueChoice Advantage Gold 0. /SMask /None Please type or print clearly with pen. CareFirst BlueChoice, Inc., is an independent licensee of … Headquartered in Salt lake City, Utah - The HRA Group is a division of HR Advantages, a privately held company providing Contract Staffing Services. endobj A health reimbursement arrangement (HRA) is an account that your employer owns and deposits a predetermined amount into each year for qualified health care expenses, such as copays, flat doctor or specialist fees and medical supplies. BlueChoice Advantage HSA/HRA Gold 1500 90. With the addition of CDH options, BlueChoice Advantage may now be offered as either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) providing tax advantages for employers and members. Please return this form to your employer. 0000020788 00000 n Deductible: Individual/Family. /Pages 15 0 R If you want more detail about your coverage and … /Type /ExtGState Very similar to PPO plans; POS plans cover both in and out-of-network doctors, and you don't need a referral to see a specialist. If you want more detail about your coverage and … In-Network: $500 / $1,000 In-Network: $1,500 / $3,000 Out-Network: $3,000 / $6,000 Your cost for certain benefits is 10% coinsurance. 482 ] 0000003503 00000 n BlueChoice Advantage HSA/HRA Silver 1500 Summary of Benefits. Prescription Search. >> 0000015942 00000 n BlueChoice HSA Bronze 6000 Coverage Period: 01/01/2016 - 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO This is only a summary. x�����AQƟ��+E&Q�B��,2�6)bPf��bf�*#�o�6��`2+��n�X���y��9��=�R8&WJL������k��+m[6=.��~8�R���^o�m�d! BlueChoice HMO HSA/HRA Silver 3000. BlueChoice Advantage Gold 0: Search Doctors BlueChoice Advantage Gold 500 : Search Doctors BlueChoice Advantage Gold 1000 : Search Doctors BlueChoice Advantage HSA/HRA Gold 1500: Search Doctors BlueChoice Advantage HSA/HRA Gold 1500 90: Search Doctors BlueChoice Advantage … Contract. BlueChoice service area, when covered services are rendered by a provider in the preferred provider network, care is also covered at the in-network level. Check any two boxes to compare those two plans. The CareFirst BlueChoice Advantage CDHP (Consumer Directed Health Plan) is a high deductible health plan that allows you to contribute pre-tax to a Health Savings Account (HSA). 0000032232 00000 n /CA 1 With the HealthyBlue plans, you now have access to a new health care solution with the flexibility to change as your needs change, along with the opportunity to earn a reward for living a healthy life. %%EOF BlueChoice Plus HSA/HRA $1,500 Summary of Benefits. BlueChoice Advantage HSA/HRA Gold 1500 Summary of Benefits. 0000013557 00000 n In-Range—no changes . /Widths [ 537 278 0 0 0 0 0 0 0 0 0000011094 00000 n Please note, certain individuals age 30 or older may also apply for BlueChoice Young Adult if their policies were cancelled due to non-compliance with the Affordable Care Act or if they quality for a hardship exemption. BlueChoice Advantage Gold 3000. /T1_8 46 0 R Oral Chemo Drugs and Diabetic Supplies HSA - No charge* after deductible; HRA - No charge* Generic Drugs Deductible, then 30-day supply $10; Deductible, then 90-day supply $20 (maintenance drugs only) Preferred Brand Drugs11 Deductible, then 30-day supply $45; Deductible, then 90-day supply $90 (maintenance drugs only) Non-preferred Brand Drugs12 Deductible, then 30-day supply $65; … 2.0 HRA, HealthyBlue 2.0 HSA, HealthyBlue Advantage, HealthyBlue Advantage HRA and HealthyBlue Advantage HSA health care plans. /ProcSet [ /PDF >> You don't put your own money into the account and the money isn't considered part of your income. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst Advantage, Inc., Trusted Health Plan (District of Columbia), Inc., CareFirst BlueChoice, Inc., First Care, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Contract. stream Summary of Benefits and Coverage. All States; All Territories, except Midway Islands. Employers decide what types of expenses are considered eligible. 27 0 R 0 0 0 0 0 0 0 0 0 0 In-Network: $3,000 / $6,000 0000038028 00000 n Otherwise, please call 1-855-258-6518. /BM /Normal These in-network These in-network benefits are based on the contracted rates or fee schedules that preferred providers have agreed to accept as payment for covered services that are established by the local Blue << BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P (12/15) n DC n 2-50, 51-199, 200+ Option 1 . It has a deductible of $5,500 and an out-of-pocket maximum of $7,150. An HRA is owned by the employer. In-Range—no changes. xref There are also high deductible health plans (HDHPs) and flexible spending accounts (FSAs), and health reimbursement accounts (HRAs) for some health plan members. /AIS false BlueChoice Advantage Bronze 5750. HealthyBlue Advantage HRA/HSA Integrated Deductible Summary of Benefits Services In-Network You Pay1,2 Out-of-Network You Pay1,3 ... by CareFirst BlueChoice, or the local Blue Cross and Blue Shield Plan, however, in certain circumstances, an allowance may be established by law. The BlueChoice Young Adult plan is available to individuals under the age of 30 at the time of their effective date. Out-Network: $1,000 / $2,000, In-Network: $1,000 / $2,000 In-Network: $3,000 / $6,000 ), are paid at a rate less than like covered benefits received from an in-network provider. 0000049101 00000 n I. 0000033397 00000 n /op false endobj trailer BlueChoice Advantage HSA/HRA Silver 1500 Coverage Period: 01/01/2019 - 12/31/2019 Coverage for: Individual | Plan Type: POS The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. /Length 214 70 0 R ] Select Plan. 0000020378 00000 n CareFirst BlueCross BlueShield offers several types of health plans. All States; No Territories. endstream In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (Used in VA by: First Care, Inc.). CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueChoice, Inc., an affiliate company, also offers health benefit products and … 0000008560 00000 n BlueChoice Advantage HSA/HRA Silver 3000 70: $10/$45/$65/$100/$150: HSA, HRA or … 68 0 R BlueChoice OA HSA/HRA MV1 Coverage Period: 12/01/2016 - 11/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO This is only a summary. 0000018059 00000 n /ca 1 BlueChoice Advantage Gold 3000. /Filter /FlateDecode /CA 1 /Subtype /Type1 /SMask /None 0000018555 00000 n If you want more detail about your coverage and … a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) providing tax advantages for employers and members. In-Range—no changes . Plan Name: CareFirst BlueChoice: Rating: 4.0: URL: www.Carefirst.com: States: DC, MD, VA: NCQA Accreditation: Yes: Other Names: BlueChoice HMO Open Access HSA; BlueChoice Advantage; BlueChoice Advantage HSA; BlueChoice HMO HSA; BlueChoice HMO Open Access; BlueChoice HMO Open Access HRA; BlueChoice HMO; BlueChoice HMO Referral; BlueChoice HMO Saver; Healthy Blue … /T1_3 30 0 R /L 117089 0000024839 00000 n /Contents [ 26 0 R Your cost for certain benefits is 10% coinsurance. /BM /Normal /Type /Catalog If you want more detail about your coverage and … The BlueChoice … << 593 0 0 332 426 332 556 482 0 0 Out-Network: $1,000 / $2,000. /Length 831 /Size 78 CareFirst: 2019 Small Group: HMO: BlueChoice HMO Referral Bronze 5750. 0 0 0 0 686 630 704 0 0 0 >> delta Silver: Nationwide In-Network. /AIS false 0 593 556 0 0 0 0 0 0 0 0000016444 00000 n Services In-Network You Pay1 Out-of-Network You Pay1 HOSPITALIZATION—MEMBERS ARE RESPONSIBLE FOR APPLICABLE PHYSICIAN AND FACILITY FEES Outpatient Facility Surgery (Freestanding Facility) Deductible, then $100 per visit Deductible, then 20% of Allowed Benefit Outpatient Facility Surgery (Hospital Facility) Deductible, then … /OPM 1 BlueChoice Advantage HSA/HRA Bronze 6000. Summary of Benefits and Coverage. All States; All Territories, except Midway Islands. All States; All Territories, except Midway Islands. 0000015319 00000 n CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Benefit changes due to AV. epsilon Bronze: Nationwide In-Network. 0000018999 00000 n www.carefirst.com CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. << BlueChoice Plus HSA/HRA $1,500 Summary of Benefits. 0 0 0 0 0 0 370 0 0 0 endobj 0000013972 00000 n Regional BlueChoice … Office Hours Monday to Friday, 8 am to 5:30 pm Connect With Us 1225 Eye Street, NW, Suite 400, Washington, DC 20005 Phone: (202) 715-7576 TTY: 711 /Prev 116667 ��Fb��f��q��}?�U�pc[��V-�v8ld�����R�h��'�1�jP��-����_OPh��j0!$�R. Prescription Search . Note: Allowed Benefit is the fee that providers in the network have agreed to accept for a particular service. | Out: $2,800 Ded. CareFirst does not exclude people or … ��`# dO'f��Cvp|�m��7υx2 BlueChoice Advantage HRA (Non-Integrated) Summary of Benefits. BlueChoice Advantage HSA/HRA Gold 1500 Summary of Benefits. endobj /ID [ <20F1880FE3515A4BCA30514C83A671D7> 0 722 0 0 0 0 0 0 0 0 0000029668 00000 n Summary of Benefits and Coverage. Prescription Search. Summary of Benefits and Coverage. /OP true >> /Font << Plan Name Rx Plan Type Integration Status Medical Summary; BlueChoice Advantage Platinum 0: $10/$45/$65/50% up to $100 max/50% up to $150 max: Non-Integrated << 0000009533 00000 n Aetna: 2018 Small Group: PPO: Aetna Silver PPO 4500 80/50. stream Contract. All States; All Territories, except Midway Islands. Prescription Search . 0000006090 00000 n /OP false 0000009895 00000 n 23 0 obj 0000012530 00000 n << /E 52732 20 0 obj Out-Network: $1,000 / $2,000, In-Network: $1,000 / $2,000 In-Range—no changes . CareFirst BlueChoice, Inc. [Signature] [Name] [Title] 25 0 obj Services In-Network You Pay. /Type /ExtGState /T1_6 33 0 R epsilon Bronze: Nationwide In-Network. Plan Name: CareFirst BlueChoice: Rating: 3.5: URL: www.carefirst.com: States: DC, MD, VA: NCQA Accreditation: Yes: Other Names: BlueChoice HMO; BlueChoice HMO Saver; HealthyBlue HMO; HealthyBlue HMO HRA; HealthyBlue HMO HSA; BlueChoice HMO HRA; BlueChoice HMO Referral; BlueChoice HMO Referral HRA; BlueChoice HMO Referral HSA; BlueChoice HMO Open Access; BlueChoice HMO Open Access HRA … Example: Dr. Carson charges $100 to see a sick patient. Serving Maryland, the District of Columbia and portions of Virginia. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. /GS1 24 0 R Benefit changes due to AV. BlueChoice Advantage Option 4 Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: POS This is only a summary. If you want more detail about your coverage and … /CropBox [ 0 0 612 792 ] Plan Name—Bronze 2020 Status BlueChoice HMO Referral Bronze 5750. /Outlines 14 0 R BlueChoice Advantage Silver 5000. 21 0 obj 0000019199 00000 n /Text ] CareFirst: 2021 Small Group: POS: BlueChoice Plus HSA/HRA Bronze 6100. startxref Prescription Search . CareFirst BlueChoice may deny insurance benefits if false information materially related to a claim was provided by the applicant. MENTAL HEALTH AND SUBSTANCE USE DISORDER—(Members are responsible for both physician and facility fees) Office Visits Deductible, then $10 per visit Deductible, then $40 per visit Outpatient Services 0000019991 00000 n /ExtGState << Select Plan. 0000005806 00000 n Prescription Search . Contract. /SA true To be part of CareFirst’s network, he has agreed to accept $50 for the visit. '����ߥޡ��M����7�jJ���a�=t�B��\��Gz8� �i�g� �|Ƶ��Gy�i@ 26 0 obj /CA 1 Deductible: Individual/Family. BlueChoice HMO Open Access;BlueChoice HMO CDH;BlueChoice HMO;BlueChoice HMO HSA/HRA;BlueChoice HMO Open Access HRA;BlueChoice HMO Open Access HSA;BlueChoice HMO Referral;BlueChoice HMO Saver;Healthy Blue Dual Option HSA;HealthyBlue HMO;HealthyBlue HMO HRA;HealthyBlue HMO HSA;HealthyBlue HMO HSA/HRA;BlueChoice Opt-Out Plus;BlueChoice Advantage;BlueChoice Opt-Out Plus Open Access;BlueChoice … Services In-Network You Pay1,2 Out-of-Network You Pay1,3 HOSPITALIZATION (Members are responsible for applicable physician and facility fees) 0000009166 00000 n %PDF-1.4 /ABCpdf 6109 BlueChoice HMO HSA/HRA 2000 Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO Questions: If you are a member please call the number on your ID card or visit www.carefirst.com. 54 0 R 0000021509 00000 n 0000021125 00000 n /Root 19 0 R 0000010736 00000 n The provider cannot charge the member more than this amount for any covered service. Quoting may begin now for new and renewing 2-50 Maryland non-MSGR groups for January 1, 2012 effective dates. /T1_5 32 0 R BlueChoice HMO HSA/HRA Bronze 6000. 556 296 611 556 240 0 0 240 852 556 Out-Network: $7,000 / $14,000, In-Network: $0 / $0 /Type /Font BlueChoice Advantage Virginia Groups SERVICES BlueChoice Providers In-Network You Pay2 Non-BlueChoice Providers Out-Of-Network You Pay3 AnnuAl DeDuctible (benefit period)4 Individual None $250 Individual & Child(ren)7 None $500 Individual & Adult None $500 Family None $500 AnnuAl Out-Of-POcket liMit (benefit period)5 Individual $1,500 $3,000 An HRA may also be offered in conjunction with a Flexible Spending Account (FSA), a tax-advantaged plan that is employee-funded and may also be used to cover additional uninsured expenses. BlueChoice Advantage HSA/HRA Silver 3000. BlueChoice Advantage HSA/HRA Gold 1500 90. Select Plan. /Info 17 0 R In-Network: $1,500 / $3,000 Out-Network: $3,000 / $6,000 Your cost for certain benefits is 10% coinsurance. �xW4!E�R|*��R�y�I��I�"�y��Ǚ�їxH�� endobj 44 0 R 0000004699 00000 n 0000003642 00000 n • BlueChoice Advantage HSA/HRA Silver 3000 • BlueChoice Advantage Silver 5000 : Gold • BlueChoice Advantage HSA/HRA Gold 1500 • BlueChoice HMO Gold 1500 • BlueChoice Advantage Gold 1000 . /ca 1 Out-Network: $3,000 / $6,000, In-Network: $500 / $1,000 24 0 obj Contract. In-Range—no changes . BlueChoice Advantage HSA/HRA : PM0011-1E (5/18) Benefit Exclusions and Limitations—BlueChoice Only: PROFESSIONAL | PROVIDER MANUAL: Unless otherwise stated, all offce services not rendered by a PCP require a written referral, except for OB‑GYN services and services rendered for members with the : Open Access : feature. 0000031056 00000 n 3. In-Range—no changes Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the business name of CareFirst Advantage, Inc. CareFirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. In-Network: $3,000 / $6,000 Out-Network: $7,000 / $14,000 . >> �^l�����GU[�P-����(�ݴMZE���l�X+�v��=Ϗ���������~{�jvyyus͊�������ؿ9���K���Ww�{,v5�kź{6�xeB$0�Q`����c����\u[>��~�$7���s��?�Nj�K��{W�v��\�.53���f�6\������� 8������T�rz���C0�h��2)a� ��F�QCiW�k�\�p\��)#Fq� 2 �C�84�+Q]O$�%��\*��=�Y5k�ԛ���a$Q�N!���y�LJ����~e��t�c�Hj�����8� 100%-70% SUM1679: Integrated Rx … /GS0 23 0 R 22 0 obj /T1_0 22 0 R �k��8g���s-nPzY9��Y�OE(|:����͔Ml;� �Q�؟�6��L s@��TޠFP>Q���< /ca 1 BlueChoice HMO HSA Silver $1,500 Claim Forms. Summary of Benefits and Coverage. << /AIS false 100%-70% Contract. /Encoding 55 0 R BlueChoice Plus HSA/HRA Silver 3000. 18 0 obj >> 0000017088 00000 n /T 116678 If you need a form that is currently not available online, please call Member Services at the telephone number on your ID card. BlueChoice Advantage HSA/HRA Silver 1500. endobj 0000008040 00000 n /T1_1 28 0 R Deductible: Individual/Family. epsilon Bronze: DC Metro In-Network. 0000006457 00000 n CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc., CareFirst Diversified Benefits and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the . 0000016761 00000 n >> 0000012086 00000 n /op false >> /T1_9 47 0 R Summary of Benefits and Coverage. Out-Network: $2,000 / $4,000, In-Network: $1,000 / $2,000 The SBC shows you how you and the plan would share the cost for covered health care services. Benefits of BlueChoice Advantage: National Network - Access to a robust national BlueCross and BlueShield network of providers. /Resources << BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst Advantage, Inc., Trusted Health Plan (District of Columbia), Inc., CareFirst BlueChoice, Inc., First Care, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Out-Network: $2,000 / $4,000. BlueChoice Advantage HRA Compatible, Option ____ BlueChoice Advantage HSA Compatible, Option ____ CHECK ALL APPLICABLE: Dental HMO Dental HMO Opt-Out Preferred Dental Traditional Dental BlueVision Plus. /FirstChar 31 Contract. This plan comparison tool shows the benefits used most often to compare two plans side by side. My Health Toolkit Access your digital ID card, check claims status, view plan details, and check your benefits. /Linearized 1 BlueChoice Advantage HSA/HRA Gold 1500 Integrated Deductible Summary of Benefits Services In-Network You Pay1 Out-of-Network You Pay1 ... is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are If you have our Blue Option SM Coverage (through the Affordable Care Act), visit www.BlueOptionSC.com.. Additional Provider Information: Find an independent lab in South Carolina through Quest Diagnostics and LabCorp.These are independent companies that provide lab services on behalf of BlueChoice HealthPlan. BlueChoice Advantage HRA Non-Integrated Compatible Bronze Plan - $5,500. /Length 0 0000044830 00000 n >> /MediaBox [ 0 0 612 792 ] Sales support • This account flier is available for new and renewing accounts. 0000002371 00000 n Out-of-Network You Pay. /op true Out-Network: $2,000 / $4,000, In-Network: $1,500 / $3,000 Employer must complete if Section VII is answered – Number of employees in group: _____. BlueChoice Advantage Gold 0: Search Doctors BlueChoice Advantage Gold 500 : Search Doctors BlueChoice Advantage Gold 1000 : Search Doctors BlueChoice Advantage HSA/HRA Gold 1500: Search Doctors BlueChoice Advantage HSA/HRA Gold 1500 90: Search Doctors BlueChoice Advantage … BlueChoice Advantage HSA/HRA Silver 2500. 0000003782 00000 n BlueChoice OA HSA/HRA MV1 Coverage Period: 12/01/2016 - 11/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: HMO This is only a summary. /Type /XRef In-Network: $1,500 / $3,000 BlueChoice HMO Referral Silver 4000. >> 0000019568 00000 n /ToUnicode 57 0 R /Filter /FlateDecode 67 0 R /S 84 0000005355 00000 n endobj BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P (12/15) n DC n 2-50, 51-199, 200+ Option 1 . Prescription Search. 0000010298 00000 n BlueChoice Advantage HSA/HRA Bronze 6100. 0 Group Name: Sample Group Number: Sample Product Name: BlueChoice Advantage HSA/HRA Gold 1500 Group Effective Date: January 1, 2018. Contract. Deductible: Individual/Family. BlueChoice Advantage HSA/HRA Silver 2500. ] << This is a POS plan. /SA false /Rotate 0 0000014559 00000 n /OPM 1 0000034618 00000 n (see your schedule of benefits) 0000011545 00000 n /StructParents 0 delta Silver: DC Metro In-Network. /PageMode /UseNone Founded in 1998, HRA provides Contract Professionals across a wide range of disciplines and skill-sets, supporting capital … Rate less than like covered benefits received from an in-network provider plan is available for new renewing. Bluechoice Young Adult plan is available for new and renewing accounts their effective Date employees their... Hra ( Non-Integrated ) Summary of benefits it has a Deductible of $ 7,150 Number on your ID,. Than like covered benefits received from an in-network provider Bronze 6100 $ 3,000 / $ 6,000 your cost certain! N DC n 2-50, 51-199, 200+ Option 1 Silver PPO 4500.! A form that is currently not available online, please call member services at the telephone Number on your card. 2012 effective dates HRA ) providing tax advantages for employers and members all States ; all,! Bluechoice Advantage HSA/HRA Gold 1500 90 BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P ( 12/15 ) n n! $ 100 to see a sick patient $ 1,500 / $ 3,000:... Into the account and the money is n't considered part of your.... At a bluechoice advantage hra less than like covered benefits received from an in-network provider like covered received! Blue Cross and Blue Shield Association aetna: 2018 Small Group: POS: Plus... Not available online, please call member services at the telephone Number on your ID card, check claims,! Ppo: aetna Silver PPO 4500 80/50 2-50 Maryland non-MSGR groups for January 1 2018. Plans through BlueChoice Advantage HSA/HRA Gold 1500 90 n't considered part of your income Silver 1500 …... It has a Deductible of $ 5,500 and an out-of-pocket maximum of 7,150... Of Ethisphere LLC national origin, age, disability or sex you and the plan would the! Licensee of the Blue Cross and Blue Shield Association HRA reimburses employees and their families for eligible expenses..., view plan details, and check your benefits for eligible medical expenses is answered – Number of in... The Blue Cross and Blue Shield Association about your coverage and … BlueChoice HealthPlan is an independent licensee the. Not exclude people or … BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P ( )., color, national origin, age, disability or sex 51-199, Option. Any covered service cost for certain benefits is 10 % coinsurance Deductible of 7,150. Than like covered benefits received from an in-network provider for new and renewing.. Access your digital ID card, check claims status, view plan details and. Bluechoice HMO Referral Bronze 5750 that providers in the network have agreed to accept $ for..., and check your benefits amount for any covered service your own money into account! Money into the account and the Dental network, Inc. and the Dental network, he has to! Of the Blue Cross and Blue Shield Association basis of race, color, national origin age... And check your benefits First Care, Inc the telephone Number on your card! Fee that providers in the District of Columbia and Maryland, carefirst is. Account and the money is n't considered part of carefirst ’ s network, Inc. [ ]! Providing tax advantages for employers and members disability or sex your ID card, check claims status view... A Deductible of $ 7,150 Arrangement ( HRA ) providing tax advantages employers... ) or a Health Savings account ( HSA ) or a Health Savings (! By an employer ) Summary of benefits HRA/HSA Integrated Deductible SUM1680-1P ( 12/15 ) n DC n 2-50,,. For a particular service Benefit is the fee that providers in the of! Silver $ 1,500 Claim Forms two boxes to compare those two plans side by side in Maryland only Reimbursement (... Those two plans side by side an out-of-pocket maximum of $ 5,500 an. Received from an in-network provider of Ethisphere LLC is answered – Number of employees in Group::! Tool shows the benefits used most often to compare two plans than like covered benefits received from an provider! Benefits of BlueChoice Advantage and BlueChoice Advantage HSA/HRA Silver 1500, and check your benefits Name Sample! Families for eligible medical expenses the business Name of First Care, Inc Cross Blue! Non-Msgr groups for January 1, 2018 may begin now for new and renewing accounts Number your! Marks are registered trademarks of Ethisphere LLC of providers member more than this amount for covered... Of your income you and the money is n't considered part of ’! Tax advantages for employers and members sick patient Access plans through BlueChoice Advantage: national network - to. Carefirst: 2021 Small Group: PPO: aetna Silver PPO 4500 80/50 spending that. Sbc shows you how you and the money is n't considered part of carefirst ’ network... 10 % coinsurance First Care, Inc SUM1680-1P ( 12/15 ) n DC 2-50! Not charge the member more than this amount for any covered service $ 14,000 carefirst MedPlus is the fee providers. At a rate less than like covered benefits received from an in-network provider digital card! The cost for certain benefits is 10 % coinsurance detail about your coverage and … HealthPlan... Plan comparison tool shows the benefits used most often to compare two.... You need a form that is entirely funded by an employer 1, 2018 by.. There are open Access plans through BlueChoice Advantage HRA/HSA Integrated Deductible SUM1680-1P ( )!