- Plan Benefits Summary (2016)
- Pharmacy Benefit Summary (2016)
- Summary of Benefits and Coverage (SBC, 2016)
- Plan Benefits Summary (2017)
- Pharmacy Benefits Summary (2017)
- Summary of Benefits and Coverage (SBC, 2017)
Yes! There are two CareFirst BlueChoice Advantage plans available: the Point of Service (POS) and the Consumer-Driven Health Plan (CDHP) with Health Savings Account (HSA). You can compare them side-to-side in this chart.
No CareFirst Card? There's an app for that!
You don't need a physical ID card to seek services. Use the mobile app to get your member information on the go, or log in to the My Account section of CareFirst.com to print a verification of coverage. Don't know your member ID? That's okay too! You can register with My Account using your social security number, or call Member Services at 877-691-5856 to get it.
The CareFirst BlueChoice Advantage plan allows members the flexibility to choose a health care provider when and where treatment is needed. When care is received inside the CareFirst service area members will experience the lowest out of pocket costs when they visit a BlueChoice provider. Members still have the option to access a BlueCard PPO doctor, but will be subject to higher out of pocket expenses.
Members receiving care outside the CareFirst Service area will experience the lowest out of pocket costs by accessing a national BlueCard PPO provider. Members will still have the option to opt-out of this network at a higher out of pocket expense.
- No PCP selection required
- No referrals needed to see a plan specialist (some exceptions may apply)
- Freedom to choose any doctor, specialist or hospital - anytime you wish
- No claims to file when visiting a plan provider
- No balance billing for out-of-network services by CareFirst BlueCross BlueShield participating providers. Members can see a provider who is not in the Blue Cross Blue Shield network, but may pay a higher out-of-pocket cost and members typically must file their own claims.
- Preventive Care and Wellness Benefits:
- Well-child care and immunizations
- Women's health coverage, such as routine mammograms and Pap tests, with no written referrals required for routine gynecological and obstetrical care
- Men's health coverage, including routine prostate cancer screening
If you recently elected CareFirst BlueChoice as your medical plan and have not yet received an ID card, you can access temporary ID cards online through their My Account feature on www.carefirst.com or call 1-877-691-5856.
Provider Network Access
The CareFirst BlueChoice Advantage plan provides you with different ways to access care:
- BlueChoice Network: Use this network when seeking in-network benefits in the DC/MD/Northern Virginia area. A more strictly defined network of local providers. With no deductible or coinsurance, members typically pay only a copay at time of service.
- BlueCard PPO Network: Use this network when seeking in-network benefits outside of the DC/MD/Northern Viriginia area.
- BCBS Participating Network (BCBS provider): Members also have freedom of choice and out-of-pocket savings received through tradional medical coverage by using BCBS-participating providers. Deductible and coinsurance apply. Over 80% of all providers nationwide participate in the BlueCross BlueShield (BCBS) network. You’ll pay more, but generally less than going completely non-network. Click here to read more.
- Non-Network (non-BCBS provider): Providers who do not participate in either the BlueChoice network or “par” network. Members may see a provider who is not a member of the BlueCross BlueShield network but may pay a higher out-of-pocket cost due to balance billing. Members typically must file their own claims.
Finding a Doctor
The BlueChoice network is a local network of providers. To locate a medical provider, go to CareFirst's online directory and look for providers in the "BlueChoice Advantage" network. You may also use this online directory to search for BlueCard PPO providers outside of the local area. Follow the instructions above, then click on the link for providers outside the Metro area. Need help finding a doctor? Health Advocate is there to help.
Vision: If you are interested in receiving a routine eye exam you must access care within the Davis Vision Network. When looking for participating doctors from www.carefirst.com, be sure to select "Vision" when conducting your search.
Mental Health: Mental health service through CareFirst are administered by Magellan. To find a provider, visit CareFirst's Provider Directory page and click the link at the bottom for Magellan.
In-Network (BlueChoice) versus BCBS "Participating " or "Traditional" Providers
In order to access ‘in-network’ care, and receive the greatest benefit with the lowest out-of-pocket expense, visit a BlueChoice network provider when seeking care in DC/MD/Northern VA, and a BlueCard PPO provider outside of the metro area. In the CareFirst BlueChoice Advantage plan, you may also choose to access your care from a non-network provider. There are two types of non-network providers: ‘par’ and ‘non-par.’
A ‘par’ provider does not participate in the local BlueChoice network, however, they do participate in the "Traditional/Indemnity" or national BlueCross Blue Shield (BCBS) participating provider, or ‘par,’ network. This means that although you’ll pay more than you would when seeking care from a BlueChoice doctor, you’ll pay less than you would by going completely out of the BCBS network and you’ll avoid balance billing. Par providers constitute approximately 80% of all doctors nationwide. Non-par providers do not participate in BlueCross BlueShield.
Prescription Drug Plan
Participants in the CareFirst BlueChoice plan automatically participate in the tiered prescription drug plan which is integrated into and administered by CareFirst. Refer to the Formulary at CareFirst.com to see which prescriptions are covered and which tier they fall into. You can choose between retail and mail order options. If you are a member of the CareFirst BlueChoice plan, and take maintenance prescription medication, we encourage you to investigate the mail order option. Click here to learn more about the mail-order prescription drug benefit available through CareFirst BlueChoice.
Filing a Claim
When you use a BlueChoice network or BCBS participating provider, that provider will submit your claim to CareFirst BluceChoice on your behalf. CareFirst will pay the provider as determined by plan rules and send you an Explanation of Benefits (EOB) which details for you the total amount billed by the provider, the amount that CareFirst paid, and the amount for which you are responsible. Your provider will send you an invoice for the amount owed (if any).
When you use a non-network provider, your provider may require you to pay the full bill at the time the service is rendered. You should then submit a copy of your invoice to CareFirst BlueChoice, along with a claim form. CareFirst will reimburse you for any amount determined to be payable by the Plan.
Need help resolving a claim or billing issue? Health Advocate is there to help.