FY2011 Health Benefits Booklet

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26 s u m m a r y o f g e n e r a l b e n e f i t s j u l y 2 0 1 0 – j u n e 2 0 1 1 CAREFirst Benefit PPO In-Network PPO Out-of-Network Pos In-Network Pos Out-of-Network EPO In-Network Only CAREFIRST OTHER SERvICES AND suPPLIES Acupuncture Services for Chronic Pain Management 100% of allowed benefit after $20 copay when preauthorized by Plan 80% of allowed benefit after deductible 100% of allowed benefit with PCP referral 80% of allowed benefit after deductible 100% of allowed benefit when preauthorized by Plan Cardiac Rehabilitation † 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit with PCP referral 80% of allowed benefit after deductible 100% of allowed benefit Chiropractic Services 100% of allowed benefit after $20 copay 80% of allowed benefit after deductible 100% of allowed benefit with PCP referral 80% of allowed benefit after deductible 100% of allowed benefit Dental Services Not covered Not covered Not covered Not covered Not covered Diabetic Nutritional Counseling, as mandated by Maryland Law 100% of allowed benefit after $15 copay 80% of allowed benefit after deductible 100% of allowed benefit after $15 copay with PCP referral 80% of allowed benefit after deductible 100% of allowed benefit after $15 copay Durable Medical Equipment 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit Contact CareFirst for details on covered items. Extended Care Facility (requires preauthorization) Family Planning And Fertility Testing 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit Skilled nursing care and extended care facility benefits are limited to 180 days per benefit period as long as skilled nursing care is medically necessary. Inpatient care primarily for or solely for rehabilitation is not covered. 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit with PCP referral other than GYN 80% of allowed benefit after deductible Family Planning benefits include: sperm count hysterosalpingography, eudiometrical biopsy, UD insertion, vasectomy, and tubal ligation. 100% of allowed benefit Home Health Care (requires preauthorization) 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit 80% of allowed benefit after deductible ††† 100% of allowed benefit Home Health Care benefits are limited to 120 days per plan year. Hospice Care (requires preauthorization) In Vitro Fertilization (IVF) and Artificial Insemination (AI) †† (requires preauthorization) Contact CareFirst for further details Medical Supplies 100% of allowed benefit 100% of allowed benefit for up to 3 attempts of AI and 3 attempts of IVF per live birth, lifetime maximum of $100,000 100% of allowed benefit 80% of allowed benefit after deductible 80% of allowed benefit after deductible for up to 3 attempts of AI and 3 attempts of IVF per live birth, lifetime maximum of $100,000 80% of allowed benefit after deductible 100% of allowed benefit 100% of allowed benefit with PCP referral for up to 3 attempts of AI and 3 attempts of IVF per live birth, lifetime maximum of $100,000 100% of allowed benefit 100% of allowed benefit after deductible ††† 80% of allowed benefit after deductible for up to 3 attempts of AI and 3 attempts of IVF per live birth, lifetime maximum of $100,000 80% of allowed benefit after deductible ††† 100% of allowed benefit 100% of allowed benefit for up to 3 attempts of AI and 3 attempts of IVF per live birth, lifetime maximum of $100,000 100% of allowed benefit Includes, but not limited to: surgical dressings; casts; splints; syringes; dressings for cancer, burns, or diabetic ulcers; catheters; colostomy bags; oxygen; supplies for renal dialysis equipment and machines; and all diabetic supplies as mandated by Maryland law. Benefit chart footnotes are on page 33
Maryland State Employees and Retirees 27 CAREFirst Benefit PPO In-Network PPO Out-of-Network Pos In-Network CAREFIRST OTHER SERvICES AND suPPLIES (Continued) Mental Health/ Substance Abuse Not covered by Plan Not covered by Plan Not covered by Plan See the Mental Health/Substance Abuse Benefits section for more information (does not apply to EPOs) Covered by State’s Mental Health Plan Covered by State’s Mental Health Plan Covered by State’s Mental Health Plan See pages 34-36 for mental health benefits. Pos Out-of-Network Not covered by Plan Covered by State’s Mental Health Plan EPO In-Network Only Inpatient care: 100% of allowed benefit when preauthorized by Plan Outpatient care: 100% of allowed benefit after $15 copay CAREFIRST Outpatient Prescription Drugs Not covered Not covered Not covered Not covered Not covered Private Duty Nursing (must be preauthorized) 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit Surgical Second Opinion 100% of allowed benefit 100% of allowed benefit 100% of allowed benefit 100% of allowed benefit 100% of allowed benefit Urgent Care Centers 100% after $20 copay 80% of allowed benefit after deductible 100% after $20 copay 80% of allowed benefit after deductible $20 copay Whole Blood Charges 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit CAREFIRST vISION SERvICES AND suPPLIES Vision – Medical Any services that deal with the medical health of the eye 100% of allowed benefit after $15 copay (primary care physician) or $25 copay (specialist) 80% of allowed benefit after deductible 100% of allowed benefit after $15 copay (primary care physician) or $25 copay (specialist) (when rendered by Preferred Provider) 80% of allowed benefit after deductible ††† 100% of allowed benefit after $15 copay (primary care physician) or $25 copay (specialist) Vision – Routine Any services that deal with correcting vision (provided by CareFirst) Exam: Plan pays up to $45 (available once every plan year) Prescription lenses (per pair – available once every plan year): u Single vision: $28.80 u Bifocal, single: $48.60 u Bifocal, double: $88.20 u Trifocal: $70.20 u Aphakic – glass: $54.00 u Aphakic – plastic: $126.00 u Aphakic – aspheric: $162.00 Frames: Plan pays up to $45 (available once every plan year) Contacts (per pair, instead of frames and lenses – available once every plan year): u Medically necessary: $201.60 u Cosmetic: $50.40 You may obtain vision services from any licensed vision provider, whether in the CareFirst network or not. However, you may have to pay the full cost up front and submit a claim form to CareFirst for partial reimbursement. To obtain vision benefits, you must contact CareFirst for more information. Vision benefits are available once every plan year.
Page 1 and 2: State of Maryland July 2010 - June
Page 3 and 4: Table of Contents Introduction.....
Page 5 and 6: Maryland State Employees and Retire
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Maryland State Employees and Retire
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DEPARTMENT OF BUDGET & MANAGEMENT 3
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