Blue Choice HMO Benefits - Harford County Public Schools

SECTION 13
SCHEDULE OF BENEFITS
CareFirst BlueChoice pays only for Covered Services. The Member pays for services, supplies or care,
which are not covered. The Member pays any applicable Deductible, Coinsurance or Copayment.
Services that are not listed in the Description of Covered Services, or are listed in Exclusions and
Limitations, are not Covered Services.
When determining the benefits a Member may receive, CareFirst BlueChoice considers all provisions of
the Contract, its medical policies, and its operating procedures. When these policies and procedures are
not followed, payments for benefits may be denied. Certain Utilization Management Requirements may
apply. When these requirements are not met, payments may be denied or reduced.
Term
Definition
Coinsurance:
The percentage of the Allowed Benefit allocated between CareFirst BlueChoice
and the Member whereby CareFirst BlueChoice and the Member share in the
payment for Covered Services.
Copayment:
The dollar amount that a member must pay for certain Covered Services.
Deductible:
The dollar amount of the Allowed Benefits payable during a Benefit Period for
Covered Services which must first be incurred by the Member before CareFirst
BlueChoice will make payments for Covered Services under this Contract.
Out-of-Pocket
Maximum:
The out-of-pocket maximums limit the maximum amounts that the Member will
have to pay for his/her share of benefits in any Benefit Period. Once the Member
meets the out-of-pocket maximum, the Member will no longer be required to pay
copayments or his/her share of the Coinsurance for the remainder of that Benefit
Period.
Lifetime
Maximum
There is no lifetime maximum.
MD/GHMSI/CFMI BC (R. 10/10)
CareFirst BlueChoice
Harford County Public Schools 47 7/1/2011