Small BusinessAttentionEssential & Standard Major MedicalVirginiaOwnersWe've Got You Covered!
Choose From A Large Network of Providers in theWashington Metropolitan AreaWhether you select the Essential or the Standard plan, youand your employees will gain access to our ParticipatingProvider network in the Washington metropolitan area.Through either of these plans you also will be able to make appoint-ments to see any specialist in the network without a referral.Some benefits may also be provided by non-participating med-ical providers for a higher out-of-pocket cost.Both Plans Offer a Wide Range of BenefitsOur Essential plan provides you and your employees with basichealth care benefits, including:- Hospitalization- Professional services, including office visits, inpatient visits andsurgery, plus limited outpatient visits for mental health care orsubstance abuse treatment- Maternity care- Emergency room care- Labs and X-rays- Adult physical exams- Mammography screenings (age limits apply)- Well child care- Access to prescription drug benefits*Our Standard plan provides coverage for all of the above,plus benefits for:- Allergy treatment, including testing and injections- Audiology services- Home health care- Hospice care- Skilled nursing facility care- Rehabilitation careCoverageBoth our Essential and Standard plans cap annual out-of-pocketexpenses at $3,000 for individuals and $6,000 for two-party or family memberships. There is a $1,000,000 lifetime maximum per member.In short, whichever plan you select, you receive the samedependable coverage from a company that has set the standard forhealth care coverage in the Washington metropolitan area for thepast 60 years CareFirst BlueCross BlueShield.So, allow yourself and your employees to benefit from:- Direct access to our network of health care professionals in the Washington metropolitan area- Wellness programsDo you employ 250 workers in the state of Virginia? If so, CareFirst BlueCross BlueShield is pleased to offer you our Major Medical options the Essential and the Standard plans.*No Rx card available. Member must fill prescriptions at a pharmacy and file a claim for covered reimbursement.Whatever the size of your company or budget, we're the healthy choice.For more information, please contact us at 202-479-8595.
Benefit/Cost to MemberCovered ServicesVA Essential (Minimum)VA Standard (Maximum)MaximumsCalendar Year Deductible- Individual $500 $500- Two-Party or Family$1,000$1,000Out-Of-Pocket Limit- Individual$3,000$3,000- Two-Party or Family$6,000$6,000Lifetime Maximum (per covered member)$1,000,000$1,000,000Medical ServicesAdult Physical Exam30% of Plan Allowance30% of Plan AllowanceAllergy TreatmentNot covered30% of Plan AllowanceAmbulance Services30% of Plan Allowance30% of Plan Allowancelimited to emergency serviceslimited to emergency servicesAudiology ServicesNot covered30% of Plan AllowanceDurable Medical Equipment30% of Plan Allowance30% of Plan AllowanceEmergency Room30% of Plan Allowance30% of Plan AllowanceHome Health CareNot covered30% of Plan AllowanceHospiceNot covered30% of Plan AllowanceHospitalization30% of Plan Allowance30% of Plan AllowanceLabs & X-Rays30% of Plan Allowance30% of Plan AllowanceMammography30% of Plan Allowance30% of Plan AllowanceMaternity Care (Benefits limited to 30% of Plan Allowance30% of Plan Allowancesubscriber and spouse only)Mental Health Care and Substance Abuse Treatment- Inpatient Facility Charges30% of Plan Allowance30% of Plan Allowance(Limited to 21 days per calendar year)- Inpatient Professional Services30% of Plan Allowance30% of Plan Allowance- Outpatient 30% of Plan Allowance30% of Plan Allowance(Limited to 20 visits per calendar year)Office Visit 30% of Plan Allowance30% of Plan AllowanceSkilled Nursing FacilityNot covered30% of Plan AllowanceSurgery30% of Plan Allowance30% of Plan AllowanceWell Child Care 30% of Plan Allowance30% of Plan AllowancePrescription Drugs30% of Plan Allowance,30% of Plan Allowance,(Limited to generics unless "not available." "Not available"up to 90 day supplyup to 90 day supplymeans if physician checks dispense as written (DAW),No Rx card available.No Rx card available.or the generic drug cannot be reasonably obtained.)VisionCoverage for children onlyCoverage for children and adultsRoutine eye exam (Limited to one per calendar year)30% of Plan Allowance30% of Plan AllowanceFrames & lenses (Limited to one pair of frames & lenses per calendar year)30% of Plan Allowance30% of Plan AllowanceContact lensesNot coveredNot coveredComparison of the Virginia Essential and Standard Plans
Dental Limitations and Exclusions Essential and Standard PlansLimitations:a.In the event you transfer from the care of one Dentist to that of another Dentist during the course of treatment of any covered Dental Service, or if more than one Dentist rendersservices for one dental procedure, we will pay not more thanthe amount we would have paid had only one Dentist provided the treatment or rendered the service.b.When more than one covered Dental Service could providesuitable treatment (good dental practice as determined by theAmerican Dental Association), we have the right to determinethe covered Dental Service on which payment will be based andthe expenses that will be included as covered Dental Services.Exclusions:Benefits will not be provided for:a.Services, tests, procedures or supplies which we determine arenot necessary for the prevention, diagnosis or treatment of theMember's illness, injury or condition. Although a service orsupply is listed as covered, benefits will be provided only if it ismedically necessary and appropriate in the Member's particularcase. A service or supply is medically necessary and appropriateonly if, in our judgement it is:1. Necessary and appropriate for the symptom, diagnosis,prevention or treatment of the Member's illness, injury or condition;2. Consistent with the symptom, diagnosis, prevention or treatment of the Member's illness, injury or condition;3. The most appropriate supply, treatment or level of service that can be provided safely to the Member and, if the Member is an inpatient, can not be provided safely on an outpatient basis; and4. Not primarily for the convenience of the Member or provider.Services, supplies and accommodations will not automaticallyServiceMember CoinsuranceProphylaxis (cleaning)30% of Plan AllowanceTopical fluoride30% of Plan AllowanceSpace maintainers for early lost teeth30% of Plan AllowanceSealants for permanent molars30% of Plan AllowanceOral examinations30% of Plan AllowanceX-rays30% of Plan AllowanceDiagnostic radiographs (not available under Essential plan)30% of Plan AllowanceOral surgery30% of Plan AllowancePulpotomy30% of Plan AllowanceRoot canal treatment30% of Plan AllowanceTemporary crowns30% of Plan AllowanceEmergency care (palliative care, trauma care, repair of space maintainers,30% of Plan Allowancereplacement crowns, repair of dentures)Deductible N/AAnnual out-of-pocket maximum - $3,000 for individual coverage- $6,000 for two-party or family coverageLifetime maximum $1,000,000 per memberNote: The Essential benefit covers children <18 only. The Standard benefit covers children and adults. Dental benefits areoptional, however, if a group declines dental coverage, the Group Administrator must sign a waiver of that dental coverage.Dental Services are limited to the following:
be considered medically necessary because they were prescribedor provided by a Dentist. We may consult with professionalmedical or dental consultants, peer review committees, or otherappropriate sources for recommendations on whether the services, supplies or accommodations a Member receives aremedically necessary.b.Except as provided for in Section 3.5 of the Certificate ofCoverage, Dental Services rendered prior to the effective date ofyour coverage under this Contract, or Dental Services renderedafter the effective date if such services were begun prior to sucheffective date.c.Prescription drugs, other than injectable drugs administered bya Dentist for therapeutic purposes.d.Orthognathic surgery.eCharges exceeding the Plan Allowance for any given service.f.Benefits will not be provided for any treatment, procedure,facility, equipment, drug, drug usage, device or supply which, inour judgement, is experimental, investigational or not in accor-dance with accepted medical or dental practices and standardsin effect at the time of treatment.g.Services which are provided for or received at no charge to the Member in any federal hospital or facility, or through any federal, state or local governmental agency or department,not including Medicaid. This exclusion does not apply to carereceived in a Veteran's hospital or facility unless the care is ren-dered for a condition that is a result of the Member's military service.h.Services that are beyond the scope of the license of the providerperforming the service.i.Services or supplies for conditions that State or local laws,regulation, ordinances or similar provisions require to be provided in a public institution.j.Services or supplies received from a dental or medical department maintained by or on behalf of an employer,mutual benefit association, labor union, trust or similar persons or groups.k.Services solely on court order or as a condition of parole or probation unless approved by the Plan.l.Any illness or injury caused by War, declared or undeclared,including armed aggression.m.Any service, supply or procedure which is not specifically listedin your Contract as a covered benefit including services notspecifically listed as Covered Dental Service under Section 3.Exclusions and Limitations10.1 Medical Necessity and Appropriateness. Benefits will not beprovided for services, tests, procedures or supplies which we determine are not necessary for the prevention, diagnosis or treat-ment of the Member's illness, injury or condition. Although a serv-ice or supply is listed as covered, benefits will be provided only if it ismedically necessary and appropriate in the Member's particular case. A service or supply is medically necessary andappropriate only if, in our judgment it is:a. Necessary and appropriate for the symptom, diagnosis, pre-vention or treatment of the Member's illness, injury or condi-tion;b. Consistent with the symptom, diagnosis, prevention or treat-ment of the Member's illness, injury or condition;c. The most appropriate supply, treatment or level of servicethat can be provided safely to the Member and, if the Memberis an inpatient, cannot be provided safely on an outpatientbasis; andd. Not primarily for the convenience of the Member orprovider.Services, supplies, and accommodations will not automatically beconsidered Medically Necessary because they were prescribed by anEligible Provider. We may consult with professional medical con-sultants, peer review committees, or other appropriate sources forrecommendations on whether the services, supplies, or accommoda-tions a Member receives are Medically Necessary.10.2 Accepted Medical Practice. Benefits will not be provided forany treatment, procedure, facility, equipment, drug, drug usage,device or supply which, in our judgment, is experimental, investiga-tional or not in accordance with accepted medical or psychiatricpractices and standards in effect at the time of treatment. A serviceor supply is deemed to be experimental or investigational if:a. A preponderance of scientific data, such as controlled studiesin peer-reviewed journals or literature has not demonstratedthat its use results in an improved net health outcome for aspecific diagnosis;
b. It is not in accordance with generally accepted standards ofmedical practice; orc. It does not have federal or other required governmentalagency approval at the time it is received.d. This exclusion will not be used, however, to deny Patient Costwhen the services for Clinical Trials meet all the requirementsunder the section entitled "Clinical Trial".10.3 Free Care. Payment will not be made for services which, if theMember were not covered under the Group Contract, would havebeen provided without charge, including any charge or any portionof a charge which, by law, the provider is not permitted to bill orcollect from the patient directly.10.4 Routine Care of Feet. Benefits will not be provided for any serv-ices related to hygiene and preventative maintenance such as trim-ming of corns, calluses, flat feet, fallen arches, chronic foot strain orpartial removal of a nail without the removal of its matrix, in theabsence of an underlying health condition.10.5 Dental Care. Except as provided in not be provided for anyother type of dental care including extractions, treatment ofcavities, care of the gums or bones supporting the teeth, treatment ofperiodontal abscess, removal of impacted teeth, orthodontia, falseteeth or any other dental services or supplies, unless provided in aseparate Rider or Endorsement to this Agreement.10.6 Oral Surgery. Except as otherwise provided in the evidence ofcoverage, benefits will not be provided for procedures involving theteeth or areas surrounding the teeth including the shortening of themandible or maxillae for cosmetic purposes or for correction of malocclusion are excluded.10.7 Cosmetic Services. Benefits will not be provided for cosmeticsurgery (except benefits for Reconstructive Breast Surgery and thetreatment of morbid obesity) or other services primarily intended tocorrect, change or improve appearances. Cosmetic means a serviceor supply which is provided with the primary intent of improvingappearances and not for the purpose of restoring bodily function orcorrecting deformity resulting from disease, trauma, or previoustherapeutic intervention as determined by the Plan.10.8 Prescription Drugs. Except as provided in a separate rider orendorsement to this Agreement, benefits will not be provided forprescription drugs, unless administered to the Member in the courseof covered outpatient or inpatient treatment. Take-home prescriptions or medications, including self-administered injectionswhich can be administered by the patient or by an average individual who does not have medical training, or medicationswhich do not medically require administration by or under thedirection of a physician are not covered, except as may be providedin a separate rider or endorsement to this Agreement, even thoughthey may be dispensed or administered in a physician or provideroffice or facility.10.9 Organ Transplants. Organ transplant procedures, includingcomplications resulting from any such procedure, services or supplies related to any such procedure such as, but not limited to,high dose chemotherapy, radiation therapy or any other form oftherapy, or immunosuppressive drugs are not covered, except as pro-vided in your Agreement.10.10 Other Exclusions. Benefits will not be provided for the following:a. Services or supplies received before the effective date of yourcoverage under this Agreement.b. Treatment of sexual dysfunctions or inadequacies except sur-gical implants for impotence (medical therapy and psychiatrictreatment are not covered).c. Any procedure or treatment designed to alter an individual'sphysical characteristics to those of the opposite sex.d. Weight reduction or obesity treatment, except the surgicaltreatment of Morbid Obesity.e. Speech therapy, occupational therapy or physical therapy,unless we determine that your condition is subject toimprovement. Coverage does not include nonmedical ancil-lary services such as vocational rehabilitation, employmentcounseling, or educational therapy.f. Fees and charges relating to fitness programs, weight loss or
weight control programs, physical, pulmonary conditioningprograms or other programs involving such aspects as exer-cise, physical conditioning, use of passive or patient-activatedexercise equipment or facilities and self-care or self-help train-ing or education. Cardiac rehabilitation programs are coveredas described in your Agreement.g. Services or supplies for the medical or surgical treatment oferrors of refraction, such as myopia or hyperopia, includingbut not limited to radial keratotomy or any like or similarprocedures or any complications arising therefrom.h. Services to the extent they are covered by any governmentalunit, except in Veteran's Administration or armed forces facil-ities for services received, such as for non-service connecteddisabilities, for which the recipient is liable. Services or sup-plies for injuries or diseases related to a covered person's jobto the extent the covered person is required to be covered by aworkers' compensation law. Services or supplies resultingfrom accidental bodily injuries arising out of a motor vehicleaccident to the extent the services are payable under a med-ical expense payment provision of an automobile insurancepolicy, excluding no fault insurance.i. Services that are beyond the scope of the license of theprovider performing the service.j. Except for covered ambulance services, travel, whether or notrecommended by an Eligible Provider.k. Services or supplies for conditions that State or local laws,regulation, ordinances, or similar provisions require to beprovided in a public institution.l. Services or supplies received from a dental or medical depart-ment maintained by or on behalf of an employer, mutualassociation, labor union, trust, or similar persons or groups.m. Contraceptive devices.n. Assistive reproductive procedures, except when provided in aseparate rider or endorsement to your Agreement.o. Services solely on court order or as a condition of parole orprobation unless approved by the Plan.p. Any illness or injury caused by war, declared or undeclared,including armed aggression.q. Any service, supply or procedure which is not specifically list-ed in your Agreement as a covered benefit.r. Except as otherwise provided in the evidence of coverage,benefits will not be provided for Habilitative Services. Benefitsfor physical therapy, occupational therapy and speech therapydo not include benefits for Habilitative Services.
Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes only and does not create rights not given through the benefit plan.