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Major Medical

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

Major Medical is a cost sharing plan where members pay a percentage of the cost of the services they receive. The amount that a member is responsible for is based on the provider they choose and whether the service is covered.

This plan allows members to see the physician or specialist of their choice. Services are covered up to the Allowed Benefit.

A Comparison of Providers

If members use participating providers:

  • Claims are submitted directly to CareFirst BlueCross BlueShield (CareFirst) by the provider.
  • CareFirst will pay benefits directly to the provider.
  • The member is responsible for only the deductible and coinsurance.
  • Providers assume the responsibility for contacting CareFirst for all approval for the members' care.

If members use non-participating providers:

  • Members may have to file the claim.
  • Payment will be made to the member. The member is responsible for the difference between CareFirst BlueCross BlueShield payment and the non-participating provider's billed charges.
  • The member is responsible for having the provider contact CareFirst BlueCross BlueShield to receive necessary approval for care.

Preventive Care:

  • Well-child care, including immunizations
  • Cancer screenings
  • Mammograms
  • Pap tests

Medical Benefits:

  • Surgery
  • Hospitalization/inpatient services
  • Outpatient hospital services
  • Emergency care for injury and illness
  • Office visits for illness
  • Maternity care and infertility services
  • Diagnostic tests and X-rays
  • Home health care

3-Tier Prescription Drug Plan:

  • Tier 1 - Generic drugs (lowest out-of-pocket cost)$
  • Tier 2 - Preferred brand name drugs (higher out-of-pocket cost) $$
  • Tier 3 - Non-preferred brand name drugs (highest out-of-pocket cost) $$$

Plans typically have some member out-of-pocket costs in the form of copayments, coinsurance, deductibles or annual maximums. Please refer to your Evidence of Coverage for more information.

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 24-hours a day, 7-days a week health care advice from registered nurses who can answer your employees' health care questions and help guide them to the most appropriate care.

Dental and Vision Plans May Be Purchased Separately:

Dental Plans:

Vision Plan:

  • BlueVision Plus is a 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.

Frequently Asked Questions:

  • Click here to get answers to Frequently Asked Questions regarding this plan.
For more information about this plan, contact our Member Services Department at the phone number on your member ID card.