PDF Benefits Comparison Chart 2019

Pharmacy Benefits

CareFirst BlueChoice HDHP

Deductible

Retail (up to a 34-day supply)

Maintenance--retail or mail (up to a 90-day supply)

Combined medical and drug deductible $1,400 Self Only $2,800 Self+One/Self and Family

Generic: $0 after deductible* Preferred Brand: $50 after deductible** Non-preferred Brand: $75 after deductible Preferred Specialty: $100 after deductible*** Non-preferred Specialty: $150 after deductible***

Two times 34-day supply copay

CareFirst BlueChoice Standard

Deductible

$0

Retail (up to a 34-day supply)

Maintenance--retail or mail (up to a 90-day supply)

Generic: $0 Preferred Brand: $50 Non-preferred Brand: $75 Preferred Specialty: $100*** Non-preferred Specialty: $150***

Two times 34-day supply copay

CareFirst BlueValue Plus

Deductible Retail (up to a 34-day supply)

Maintenance--retail or mail (up to a 90-day supply)

$100 Self Only $200 Self +One/ Self and Family

Preferred Generic: $10 no deductible Preferred Brand: $50 after deductible** Preferred Generic Specialty: $100 after deductible*** Preferred Brand Specialty: $150 after deductible***

Two times 34-day supply copay

* Select generics not subject to deductible ** Preferred Brand Insulin not subject to deductible *** Specialty drugs must be filled through CVS Specialty Pharmacy

NOTE: The tier your drug falls in can vary based on the plan you select. Prior to selecting a plan, please view the Drug Calculator Tool at Understand Drug Costs at fedhmo.

2021 Rate Information

Non-Postal Premium

Bi-Weekly

Monthly

Type of Enrollment

Standard Option Self Only

Standard Option Self + One

Standard Option Self and Family

HDHP Option Self Only

HDHP Option Self + One

HDHP Option Self and Family

Blue Value Plus Option Self Only

Blue Value Plus Self + One

Blue Value Plus Option Self and Family

Enrollment Code

Gov't Share

2G4

$241.58

2G6

$517.46

2G5

$562.25

B61

$197.34

B63

$394.67

B62

$468.87

B64

$241.58

B66

$500.99

B65

$562.25

Your Share

$168.18

Gov't Share

$523.42

Your Share

$364.39

$302.05 $1,121.16 $654.45

$411.33 $1,218.21 $891.21

$65.78 $427.57 $142.52

$131.56 $855.13 $285.04

$156.29 $1,015.88 $338.63

$92.42 $523.42 $200.25

$166.99 $1,085.47 $361.82

$231.31 $1,218.21 $501.17

Postal Premium

Bi-Weekly

Type of Enrollment Standard Option Self Only

Enrollment Code

2G4

Category 1 Your Share

$164.82

Category 2 Your Share

$154.76

Standard Option Self + One

2G6

$294.86

$273.30

Standard Option Self and Family

2G5

$403.52

$380.10

HDHP Option Self Only

B61

$63.15

$54.60

HDHP Option Self + One

B63

$126.30

$109.19

HDHP Option Self and Family

B62

$150.04

$129.72

Blue Value Plus Option Self Only

B64

$89.06

$79.00

Blue Value Plus Self + One

B66

$160.32

$138.61

Blue Value Plus Option Self and Family

B65

$223.50

$200.08

CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. 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.

CST2945-1N (10/20)

2021 Benefits Summary

Let's compare: In-network care

HDHP

BVP

S

Out-of-network care

HDHP

S

No referrals

HDHP

BVP

S

$0 PCP, labs

HDHP

S

HSA/HRA eligible

HDHP

Non-preferred brand name drugs

HDHP

S

HDHP

BVP

High Deductible Health Plan

$

Blue Value Plus

$$

S

Standard

$$$

What you'll pay with each plan:

HDHP Option

Primary care doctor Specialists Virtual doctor visits Urgent care centers Maternity Inpatient hospital Outpatient hospital Surgery (ASC) Emergency room (waived if admitted) Labs X-rays Chiropractic care

After deductible you pay: $0 copay $35 copay $0 copay $50 copay 20% coinsurance 20% coinsurance $300 $100 $300 $0 copay $35 copay $35 copay

Deductible

Self Only Self + One, Self and Family

$1,400 $2,800

Out-of-Pocket Maximum (preferred providers)

Self Only Self + One, Self and Family

$5,000 $10,000

Blue Value Plus Option

Primary care doctor Specialists Virtual doctor visits Urgent care centers Maternity Inpatient hospital Outpatient hospital Surgery (ASC) Emergency room (waived if admitted) Labs X-rays Chiropractic care

No deductible $10 copay $50 copay $10 copay $50 copay 25% coinsurance 25% coinsurance $200 $150 $275 $30 copay $50 copay $50 copay

Deductible

Self Only

$0

Self + One, Self and Family

$0

Out-of-Pocket Maximum (preferred providers)

Self Only Self + One, Self and Family

$6,000 $12,000

Standard Option

Primary care doctor Specialists Virtual doctor visits Urgent care centers Maternity Inpatient hospital Outpatient hospital Surgery (ASC) Emergency room (waived if admitted) Labs X-rays Chiropractic care

No deductible $0 copay $40 copay $0 copay $50 copay 20% coinsurance 20% coinsurance $150 $100 $200 $0 copay $40 copay $40 copay

Deductible

Self Only

$0

Self + One, Self and Family

$0

Out-of-Pocket Maximum (preferred providers)

Self Only Self + One, Self and Family

$4,500 $8,000

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