BlueChoice HMO Open Access

Note: The information below briefly describes important features about this health care program. It is not a contract. A detailed description of benefits is included in the Evidence of Coverage. Please refer to the Evidence of Coverage for specific terms, conditions, limitations and exclusions.

BlueChoice HMO Open Access provides the cost savings of an HMO and the freedom to see network providers without a referral from a primary care physician (PCP). Members have the flexibility to choose a provider from a network of over 2,600 PCPs, specialty care from over 14,000 participating specialists and hospital care from 55 area hospitals. Members are required to choose a PCP upon enrollment.

The PCP will coordinate routine care and provide treatment for a variety of medical conditions. If more specialized care is required, the PCP can coordinate specialty care using a network of specialists within the CareFirst BlueChoice network. With the Open Access feature, members don't need a referral from their PCP to visit most CareFirst BlueChoice specialists.+ When members are outside of the CareFirst BlueChoice service area, benefits are available for emergency or urgent care, only. This plan is only available to groups.

Advantages:

• No referrals needed to see plan specialists+
• 365 days of hospital coverage
• No claim forms to file
• Preventive Care and Wellness Benefits
  • Annual routine examinations and office visits
  • Well-child care and immunizations
  • Women's health coverage, such as routine mammograms and Pap tests
  • Men's health coverage, including routine prostate cancer screening
• Discount dental program offers BlueChoice members savings of 20% to 40% on dental services.

3-Tier Prescription Drug Plan:

• Tier 1 - Generic copays offer the lowest cost to the member
• Tier 2 - Copays for formulary/preferred brand name drugs are higher than for generic drugs
• Tier 3 - Copays for nonformulary/nonpreferred brand name drugs have the highest level of copay
• Option may require prescription deductible and/or annual maximum

Additional Features:

• Disease management programs for members with chronic asthma, diabetes, congestive heart failure, coronary heart disease and chronic obstructive pulmonary disease (COPD)
• Quarterly wellness magazine
• Health education programs
• Great Beginnings program for expectant mothers
• Discounts on alternative therapies: Options provides discounts on alternative therapies including acupuncture, massage therapy and chiropractic care. It also provides discounts for fitness center memberships and weight loss programs.
• 24/7 Advice: FirstHelp gives you health care 24-hours a day, 7-days a week advice from registered nurses who can answer your health care questions and help guide you to the most appropriate care.

Dental Plans May Be Purchased Separately:

• DHMO Dental
• Regional Preferred (PPO) Dental
• Regional Traditional Indemnity Dental

Routine Vision Benefits:

• BlueVision provides vision coverage for members of the CareFirst BlueChoice medical plan and requires only a copayment for a routine examination and contact lens fittings and provides discounts on frames, lenses and contact lenses.
• BlueVision Plus is an enhanced vision plan that may be purchased separately. BlueVision Plus provides a routine eye examination and the opportunity to receive one pair of eyeglasses or a supply of contact lenses for a single copayment during each benefit period.

Member Handbook:

• BlueChoice HMO Open Access (932KB, 40 pgs.)

+While a referral is not needed to visit plan specialists when receiving services rendered in an office setting, pre-authorization may be needed for certain services such as mental health and substance abuse treatments and non-emergency hospitalizations, among others. Please refer to your benefits booklet (also called Evidence of Coverage) for the specific services that require pre-authorization.

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