Small Business Attention Essential & Standard Major Medical Virginia Owners We've Got You Covered!
Choose From A Large Network of Providers in the Washington Metropolitan Area W hether you select the Essential or the Standard plan, you and your employees will gain access to our Participating Provider 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 Benefits Our Essential plan provides you and your employees with basic health care benefits, including: -   Hospitalization -   Professional services, including office visits, inpatient visits and surgery, plus limited outpatient visits for mental health care or substance 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 care Coverage Both our Essential and Standard plans cap annual out-of-pocket expenses 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 same dependable coverage from a company that has set the standard for health care coverage in the Washington metropolitan area for the past 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 programs Do you employ 2–50 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 Member Covered Services VA Essential (Minimum) VA Standard (Maximum) Maximums Calendar Year Deductible Individual $500 $500 - Two-Party or Family $1,000 $1,000 Out-Of-Pocket Limit Individual $3,000 $3,000 - Two-Party or Family $6,000 $6,000 Lifetime Maximum (per covered member) $1,000,000 $1,000,000 Medical Services Adult Physical Exam 30% of Plan Allowance 30% of Plan Allowance Allergy Treatment Not covered 30% of Plan Allowance Ambulance Services 30% of Plan Allowance 30% of Plan Allowance limited to emergency services limited to emergency services Audiology Services Not covered 30% of Plan Allowance Durable Medical Equipment 30% of Plan Allowance 30% of Plan Allowance Emergency Room 30% of Plan Allowance 30% of Plan Allowance Home Health Care Not covered 30% of Plan Allowance Hospice Not covered 30% of Plan Allowance Hospitalization 30% of Plan Allowance 30% of Plan Allowance Labs & X-Rays 30% of Plan Allowance 30% of Plan Allowance Mammography 30% of Plan Allowance 30% of Plan Allowance Maternity Care (Benefits limited to 30% of Plan Allowance 30% of Plan Allowance subscriber and spouse only) Mental Health Care and Substance Abuse Treatment Inpatient Facility Charges 30% of Plan Allowance 30% of Plan Allowance (Limited to 21 days per calendar year) Inpatient Professional Services 30% of Plan Allowance 30% of Plan Allowance Outpatient 30% of Plan Allowance 30% of Plan Allowance (Limited to 20 visits per calendar year) Office Visit 30% of Plan Allowance 30% of Plan Allowance Skilled Nursing Facility Not covered 30% of Plan Allowance Surgery 30% of Plan Allowance 30% of Plan Allowance Well Child Care 30% of Plan Allowance 30% of Plan Allowance Prescription Drugs 30% of Plan Allowance, 30% of Plan Allowance, (Limited to generics unless "not available."  "Not available" up to 90 day supply up to 90 day supply means if  physician checks “dispense as written” (DAW), No Rx card available. No Rx card available. or the generic drug cannot be reasonably obtained.) Vision Coverage for children only Coverage for children and adults Routine eye exam (Limited to one per calendar year) 30% of Plan Allowance 30% of Plan Allowance Frames & lenses (Limited to one pair of  frames & lenses per calendar year) 30% of Plan Allowance 30% of Plan Allowance Contact lenses Not covered Not covered Comparison of the Virginia Essential and Standard Plans
Dental Limitations and Exclusions — Essential and Standard Plans Limitations: 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 renders services for one dental procedure, we will pay not more than the 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 provide suitable treatment (good dental practice as determined by the American Dental Association), we have the right to determine the covered Dental Service on which payment will be based and the 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 are not necessary for the prevention, diagnosis or treatment of the Member's illness, injury or condition. Although a service or supply is listed as covered, benefits will be provided only if  it is medically necessary and appropriate in the Member's particular case. A service or supply is medically necessary and appropriate only 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; and 4.  Not primarily for the convenience of the Member or provider. Services, supplies and accommodations will not automatically Service Member Coinsurance Prophylaxis (cleaning) 30% of Plan Allowance Topical fluoride 30% of Plan Allowance Space maintainers for early lost teeth 30% of Plan Allowance Sealants for permanent molars 30% of Plan Allowance Oral examinations 30% of Plan Allowance X-rays 30% of Plan Allowance Diagnostic radiographs (not available under Essential plan) 30% of Plan Allowance Oral surgery 30% of Plan Allowance Pulpotomy 30% of Plan Allowance Root canal treatment 30% of Plan Allowance Temporary crowns 30% of Plan Allowance Emergency care (palliative care, trauma care, repair of space maintainers, 30% of Plan Allowance replacement crowns, repair of dentures) Deductible — N/A Annual out-of-pocket maximum $3,000 for individual coverage $6,000 for two-party or family coverage Lifetime maximum — $1,000,000 per member Note: The Essential benefit covers children <18 only. The Standard benefit covers children and adults. Dental benefits are optional, 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 prescribed or provided by a Dentist. We may consult with professional medical or dental consultants, peer review committees, or other appropriate sources for recommendations on whether the services, supplies or accommodations a Member receives are medically necessary. b. Except as provided for in Section 3.5 of the Certificate of Coverage, Dental Services rendered prior to the effective date of your coverage under this Contract, or Dental Services rendered after the effective date if such services were begun prior to such effective date. c. Prescription drugs, other than injectable drugs administered by a Dentist for therapeutic purposes. d. Orthognathic surgery. e Charges 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, in our judgement, is experimental, investigational or not in accor- dance with accepted medical or dental practices and standards in 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 care received 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 provider performing 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 listed in your Contract as a covered benefit including services not specifically listed as Covered Dental Service under Section 3. Exclusions and Limitations 10.1 Medical Necessity and Appropriateness.  Benefits will not be provided 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 is medically necessary and appropriate in the Member's particular case.  A service or supply is medically necessary and appropriate 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 service that can be provided safely to the Member and, if the Member is an inpatient, cannot be provided safely on an outpatient basis; and d. Not primarily for the convenience of the Member or provider. Services, supplies, and accommodations will not automatically be considered Medically Necessary because they were prescribed by an Eligible Provider.  We may consult with professional medical con- sultants, peer review committees, or other appropriate sources for recommendations on whether the services, supplies, or accommoda- tions a Member receives are Medically Necessary. 10.2 Accepted Medical Practice.  Benefits will not be provided for any 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 psychiatric practices and standards in effect at the time of treatment.  A service or supply is deemed to be experimental or investigational if: a. A preponderance of scientific data, such as controlled studies in peer-reviewed journals or literature has not demonstrated that its use results in an improved net health outcome for a specific diagnosis;
b. It is not in accordance with generally accepted standards of medical practice; or c. It does not have federal or other required governmental agency approval at the time it is received. d. This exclusion will not be used, however, to deny Patient Cost when the services for Clinical Trials meet all the requirements under the section entitled "Clinical Trial". 10.3 Free Care.   Payment will not be made for services which, if  the Member were not covered under the Group Contract, would have been provided without charge, including any charge or any portion of  a charge which, by law, the provider is not permitted to bill or collect 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 or partial removal of a nail without the removal of its matrix, in the absence of an underlying health condition. 10.5 Dental Care.   Except as provided in not be provided for any other type of dental care including extractions, treatment of cavities, care of the gums or bones supporting the teeth, treatment of periodontal abscess, removal of impacted teeth, orthodontia, false teeth or any other dental services or supplies, unless provided in a separate Rider or Endorsement to this Agreement. 10.6 Oral Surgery.   Except as otherwise provided in the evidence of coverage, benefits will not be provided for procedures involving the teeth or areas surrounding the teeth including the shortening of the mandible or maxillae for cosmetic purposes or for correction of malocclusion are excluded. 10.7 Cosmetic Services.   Benefits will not be provided for cosmetic surgery (except benefits for Reconstructive Breast Surgery and the treatment of morbid obesity) or other services primarily intended to correct, change or improve appearances.   Cosmetic means a service or supply which is provided with the primary intent of improving appearances and not for the purpose of restoring bodily function or correcting deformity resulting from disease, trauma, or previous therapeutic intervention as determined by the Plan. 10.8 Prescription Drugs.   Except as provided in a separate rider or endorsement to this Agreement, benefits will not be provided for prescription drugs, unless administered to the Member in the course of covered outpatient or inpatient treatment.   Take-home prescriptions or medications, including self-administered injections which can be administered by the patient or by an average individual who does not have medical training, or medications which do not medically require administration by or under the direction of a physician are not covered, except as may be provided in a separate rider or endorsement to this Agreement, even though they may be dispensed or administered in a physician or provider office or facility. 10.9 Organ Transplants.   Organ transplant procedures, including complications 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 of therapy, 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 your coverage under this Agreement. b. Treatment of sexual dysfunctions or inadequacies except sur- gical implants for impotence (medical therapy and psychiatric treatment are not covered). c. Any procedure or treatment designed to alter an individual's physical characteristics to those of  the opposite sex. d. Weight reduction or obesity treatment, except the surgical treatment of Morbid Obesity. e. Speech therapy, occupational therapy or physical therapy, unless we determine that your condition is subject to improvement.   Coverage does not include nonmedical ancil- lary services such as vocational rehabilitation, employment counseling, or educational therapy. f. Fees and charges relating to fitness programs, weight loss or
weight control programs, physical, pulmonary conditioning programs or other programs involving such aspects as exer- cise, physical conditioning, use of passive or patient-activated exercise equipment or facilities and self-care or self-help train- ing or education.   Cardiac rehabilitation programs are covered as described in your Agreement. g. Services or supplies for the medical or surgical treatment of errors of  refraction, such as myopia or hyperopia, including but not limited to radial keratotomy or any like or similar procedures or any complications arising therefrom. h. Services to the extent they are covered by any governmental unit, except in Veteran's Administration or armed forces facil- ities for services received, such as for non-service connected disabilities, for which the recipient is liable.   Services or sup- plies for injuries or diseases related to a covered person's job to the extent the covered person is required to be covered by a workers' compensation law.   Services or supplies resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent the services are payable under a med- ical expense payment provision of an automobile insurance policy, excluding no fault insurance. i. Services that are beyond the scope of the license of the provider performing the service. j. Except for covered ambulance services, travel, whether or not recommended by an Eligible Provider. k. Services or supplies for conditions that State or local laws, regulation, ordinances, or similar provisions require to be provided in a public institution. l. Services or supplies received from a dental or medical depart- ment maintained by or on behalf  of an employer, mutual association, labor union, trust, or similar persons or groups. m. Contraceptive devices. n. Assistive reproductive procedures, except when provided in a separate rider or endorsement to your Agreement. o. Services solely on court order or as a condition of parole or probation 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. Benefits for physical therapy, occupational therapy and speech therapy do 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.