BlueChoice Opt-Out Plus Open Access (POS)

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

BlueChoice Opt-Out Plus Open Access is a point-of-service (POS) plan that offers the cost savings of an HMO and the freedom for members to visit network specialists without the need for a referral from their primary care physician (PCP). Members also have freedom of choice and out-of-pocket savings received through traditional CareFirst BlueCross BlueShield coverage. Members are required to choose a PCP upon enrollment.

BlueChoice Opt-Out Plus Open Access allows members the flexibility of choosing health care providers when treatment is needed. When care is received from the PCP, specialists, hospitals and other providers who participate in CareFirst BlueChoice's provider network, a lower out-of-pocket cost is incurred. The plan also allows members to receive care outside the CareFirst BlueChoice network from any provider with a higher out-of-pocket cost. With the Open Access feature, members don't need a referral from their PCP to receive most in- or out-of-network care.+

Advantages:

  • No referrals needed to see a plan specialist+
  • Freedom to choose any doctor, specialist or hospital - anytime members wish
  • No claims to file when visiting a BlueChoice or participating provider
  • No balance billing for out-of-network services by CareFirst BlueCross BlueShield 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:
    • 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 screenings
    • 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:

  • No-cost preventive services for children and adults
  • Disease management programs for members with chronic asthma, diabetes, congestive heart failure, coronary heart disease and chronic obstructive pulmonary disease (COPD)
  • Vitality member 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 Plans May Be Purchased Separately:

  • DHMO Dental
  • Preferred (PPO) Dental
  • Traditional 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 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:

*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 the benefits booklet (also called Evidence of Coverage) for the specific services that require pre-authorization.

For more information about this plan, contact our Member Services Department at the phone number on your member ID card.

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