New plan for 2020Blue Value PlusSee inside for details

Federal Employees Health Benefits Program 2020

carefirstcomfedhmo

Table of Contents

Why CareFirst

1

Whatrsquos New Whatrsquos Changed in 2020 2

BEFORE YOU DECIDE

How Health Insurance Works 3

Know Before You Go 4

HDHPs and HSAsHRAs 6

BENEFIT PLANS

What Plan is for Me 8

Comparing PlansmdashWhatrsquos the Same 9

HealthyBlue AdvantagemdashHDHP Option 10

Blue Value Plus Option our NEW plan 11

HealthyBluemdashStandard Option

12

In-Network Benefit Comparison 13

Pharmacy Benefits 14

WITH EVERY PLAN

Health and Wellness 15

Blue Rewards 16

Vision and Discount Dental Coverage 17

Behavioral Health and Addiction Support 18

BlueCard amp BlueCross BlueShield Global Core

19

MEMBER SERVICES

Member Services 20

Important Numbers and Contact Information 21

Notice of Nondiscrimination and Availability of Language Assistance Services 22

2020 Rate Information for CareFirst BlueChoice Inc Back cover

The information in this booklet is a summary of the benefits available under the CareFirst BlueChoice plan For more detailed information please access the 2020 BlueChoice Brochure (RI 73-718) on our website at carefirstcomfedhmo

1

Why CareFirstWhen choosing a health plan choose the brand most recognized and trusted CareFirst has highest member satisfaction ratings and is named as one of the ldquoWorldrsquos Most Ethical Companiesrdquo seven years in a row

Great benefits no hidden costs Nochargenodeductiblein-networkbenefits forpreventive care

EmergencyandurgentcareiscoveredbothinsideandoutsidetheCareFirstserviceareaofWashingtonDCMarylandandNorthernVirginia

Noreferralsrequired

Health and wellness Blue Rewardsmdashearnfinancialrewardsforparticipatinginhealth-relatedactivities

Blue365mdashgetexclusivediscountsonhealthandwellnessservicessuchasgymmembershipshealthyeatingoptionsandevenfitness gear

Health Coachingmdashcoachesareregisterednursesandtrainedprofessionalswhoprovideone-on-onesupporttohelpyoureachyourwellnessgoals

Convenience Free 247 nurse advice line

Video Visitmdashtelemedicineprovidesvirtual visits247365

Mail Service Pharmacymdashaconvenientfasthomedeliveryservice

My Accountmdashoursecurememberwebsite allowsyoutomanageyourhealthinformationanytimeanywhere

1 IN 2 AMERICANSare covered by Blue

regionally1in3nationally

99 of physicians are in-network regionally 95nationally

100 of hospitals are in-network regionally 96nationally

97 of claims are paid in-network regionally 96nationally

Resultsbasedonasurveyof2638healthplanmembersconductedbyMathewGreenwaldampAssociatesIncbetween1117and93017

ldquoWorldrsquosMostEthicalCompaniesrdquoandldquoEthisphererdquonamesandmarksareregisteredtrademarksofEthisphereLLC

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp carefirstcomfedhmo

2

Whatrsquos New Whatrsquos Changed in 2020

Whatrsquos new Blue Value PlusCareFirsthasintroducedanewplanfor2020Blue ValuePlusOptionisbasedonthestrengthofourBlueChoicenetworkinWashingtonDCMarylandandNorthernVirginiaThisplanisanin-networkonlyHMOthatfeatures

Noreferrals

No medical deductible

No member copay for preventive care

$10copayforprimarycareprovider(PCP)officevisits

$10copayforCareFirstVideoVisits(telehealthPCPvisits)

$10copayforpreferredgenericprescriptiondrugs

Upto$200inBlueRewards

Whatrsquos changedOurtwoexistingplanshavechangesthatwehavehighlightedbelowtohelpyouasyoucompareoptionsfor2020

Changes to HealthyBlue Standard Option

MedicaldeductibleWeremovedthemedicaldeductible($500Self$1000Self+OneSelfandFamily)

PrescriptiondrugsWeremovedthepharmacydeductible($100Self$200Self+OneSelfandFamily)Specialtydrugswillbelimitedtoa34-daysupplyforthefirstinitial fill

InpatientHospitalandProfessionalMemberswillpay20coinsurancein-networkforotherhospitalservicesandsupplies

MaternityCareMemberswillpay20coinsurancein-networkforprofessionalservicesatdelivery

OutpatientHospitalorAmbulatorySurgicalCenterNon-SurgicalMemberswillpay$100copayin-network

Changes for HealthyBlue AdvantagemdashHDHP Option

InpatientHospitalandProfessionalMemberswillpay20coinsuranceafterthedeductiblein-networkforotherhospitalservicesandsupplies

MaternityCareMemberswillpay20coinsuranceafterthedeductiblein-networkforprofessionalservicesatdelivery

OrthopedicandProstheticdevicesMemberswillpay25coinsuranceafterthedeductibleperdevice

AnesthesiaMemberswillpay20coinsuranceafterthedeductiblein-network

LabsX-rayOtherdiagnosticservicesServicesinanoutpatienthospitalorambulatorysurgicalcenterwillhavethefollowingin-networkcostshare

Labs$35copayafterthedeductible

X-rays$50copayafterthedeductible

Otherdiagnosticservices$50copayafterthe deductible

Specialtyimaging$100copayafterthedeductible

PrescriptiondrugsSpecialtydrugswillbelimitedtoa34-daysupplyforthefirstinitial fill

PleasenoteThisisnotacompletelistofallthechangesToseeacompletelistofbenefitchangeswithacompletedescriptionpleaserefertothe2020BlueChoiceBrochurewhichisavailableonourwebsiteatwwwcarefirstcomfedhmo

enspFederal Employees Health Benefits Programenspensp2020 Health Benefit Options carefirstcomfedhmo

3

BEFORE YOU DECIDE

How Health Insurance Works Tohelpyouunderstandyourhealthplanoptions itrsquosimportanttounderstandabitabouthealth insuranceThegraphicbelowexplainshowhealth insuranceworksanddefinessomekeyterms

Letrsquos get

started

Receive your member ID card

Get your preventive

care

Here are key benefits you get at no charge from participating providers Adultpreventivevisitswith

primarycareprovider(PCP) Well-childexamsand

immunizations OBGYNvisitsandpaptests Mammograms Prostateandcolorectalscreenings Routine prenatal maternity

services

Need additional care

Meet your deductible YourDEDUCTIBLEisthe

amountofmoneyyoumust pay each year

beforeCareFirstwill startpayingforallor partoftheservices

YOU PAY 100 until you meet your deductible

Manyofourplans donotrequire you to meet a deductible for

primary care and specialistoffice

visitsurgentcare and preventive screenings

Pay your share Afteryoumeetyour

deductible yoursquoll pay a COPAY or COINSURANCE

forcoveredservices

CAREFIRST YOU PAY BLUECHOICE PAYS Reach your annual out-of-pocket maximum

IfyoureachyourOUT-OF-POCKET MAXIMUM you will pay nothing for

your care for the remainder of the planyearCareFirstwillpay100 ofyourcoveredmedicalexpenses

CAREFIRST BLUECHOICE PAYS 100

Yourpremium doesnotcount

toward your deductible or out-of-pocket maximum

Plan year ends

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp

carefirstcomfedhmo

4

Know Before You Go Choosing the right setting for your caremdashfrom vaccinations to X-raysmdashis key to getting the best treatment with the lowest out-of-pocket costs Itrsquos important to understand your options so you can make the best decision when you or your family members need care The following information may help you decide where to go for medical treatment

enspPrimary care providers (PCP) Thebestplacetogetconsistentqualityhealthcare isyourprimarycareprovider(PCP)Ifyouhavea medicalissuehavingadoctorwhoknowsyour healthhistoryoftenmakesiteasiertogetthecare youneed

enspFree 247 nurse advice line

WhenyourPCPisnrsquotavailableregisterednurses areavailable247todiscussyoursymptomswith youandrecommendthemostappropriatecare Call800-535-9700anytimetospeakwithanurse

enspCareFirst Video Visit

WhenyourPCPisnrsquotavailableandyouneednon-emergencyservicesCareFirstVideoVisitsecurely connectsyouwithadoctor day or night through yoursmartphonetabletorcomputerInaddition youcanschedulevisitsforotherneedssuchas behavioralhealthsupportfromatherapistor psychiatristguidancefromacertifiednutritionist orbreastfeedingsupportfromalactation consultantItrsquosaconvenientandeasywaytoget thecareyouneedwhereveryouare

enspConvenience care centers

Conveniencecarecenters(retailhealthclinics)offer carefornon-emergencysituationslikecoldspink eyestreptestsandvaccinationsThesecenters usuallyhaveeveningandweekendhours

Example CVS MinuteClinic Walgreens Healthcare Clinic

enspUrgent care centers

Urgentcarecentersprovidetreatmentforinjuries andillnessesthatrequirepromptmedicalattention butarenotlife-threatening(sprainsminorcutsflu rashesminorburns)Thesecentershavedoctors onstaffandofferweekendafter-hourscare

Example Patient First ExpressCare

Outpatient hospital vs ensp

Inpatient hospital ensp

Outpatient services are received in the hospitalwithoutbeingadmittedsuchas same-daysurgeriesInpatient services are thosereceivedwhenyouareadmittedtothe hospitalPrior authorization may be needed for hospital-based services

enspEmergency rooms (ER) Emergencyroomstreatacuteillnessesandtrauma GototheERrightawayifyouorafamilymember havesuddensymptomsthatneedemergencycare including(butnotlimitedto)chestpaintrouble breathingorheadtraumaPrior authorization is not needed for ER services

Tofindparticipatingprovidersinyourplanvisit carefirstcomfedhmo

PLEASE READ The information provided in this document regarding various care options is meant to be helpful when you are seeking care and is not intended as medical advice Only a medical provider can offer medical advice The choice of provider or place to seek medical treatment belongs entirely to you Thedoctorsaccessedviathiswebsiteareindependentprovidersmakingtheirownmedicaldeterminationsandarenotemployedby CareFirstCareFirstdoesnotdirecttheactionofparticipatingprovidersorprovidemedicaladvice

SubjecttochangeVisitcarefirstcomfedhmoforthemostup-to-datelistofavailablefacilities

enspFederal Employees Health Benefits Programenspensp2020 Health Benefit Options

Non-hospital facilities and enspsurgery centers

X-rayslabworkandoutpatientsurgerywillalmost alwayscostmoreinahospitalsettingPayless fortheseservicesbygoingtoaparticipating non-hospitalfacilityorsurgerycenterPrior authorization may be required for non-hospital outpatient services

carefirstcomfedhmo

BEFORE YOU DECIDE

When your PCP is not available

YouhavefullaccesstoourexpansivenetworkofprovidersWhenyouneedcarebeingfamiliarwithallyour optionswillhelpyoulocatethemostappropriateandcost-effectivemedicalattention

Thechartbelowshowshowcostsvaryforthehealthplansdependingonwhereyoureceivecare

HealthyBlue Advantagemdash HDHP Option

Blue Value Plus Option

HealthyBluemdash Sample Symptoms Standard

Option 247 Rx

CareFirst Video Visit (urgent care services)

Deductible then $0 $10 $0

Coughcoldandflu Pinkeye Ear pain

Convenience Care (eg CVS MinuteClinicor Walgreens Healthcare Clinic)

Deductible

then $0 $10 $0 Coughcoldandflu Pinkeye Ear pain

Urgent Care (eg Patient First or ExpressCare)

Deductible then $50 $50 $50

Sprains Cutrequiring stitches

Minorburns

Emergency Room

Deductible then $300 $275 $200

Chestpain Difficultybreathing Abdominalpain

ensp Free 247 nurse advice line Ifyouareunsureaboutyoursymptomsorwheretogoforcarecall800-535-9700anytimedayornighttospeaktoa registerednurse

For more information regarding your specific benefits and associated costs Loginto My Account at carefirstcomfedhmo

Checkyour2020 BlueChoice Brochure

CallMemberServicesat888-789-9065

CareFirst Video Visit

Register today and you will be ready when you need care

1 Visitcarefirstvideovisitcom and click on any of theVideoVisitlinksor

2 DownloadtheCareFirstVideoVisitappfromyour favoriteappstore

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp

carefirstcomfedhmo 5

6

HDHPs and HSAsHRAs Our HealthyBlue AdvantagemdashHDHP Option may be a great choice if you want more control over your health care spending or if saving for future medical expenses is a priority for you

HealthyBlue Advantagemdash HDHP Option pairs ahigh-deductiblehealthplan(HDHP)with eitheraHealthSavingsAccount(HSA)orHealth ReimbursementArrangement(HRA)

RememberYouonlyhave30daystosignupfor anHSAotherwiseyouwillbeenrolledinanHRA ToenrollinanHSAvisitcarefirstcomfedhmo SelectResources amp Forms go to Forms and click on HealthyBlue Advantage-HDHP Option Forms Open the HSAHRA Selection Form andfollowinstructions tocompleteandreturntheform

FordetailsaboutyoureligibilitytoenrollinanHSA orHRApleaseseethe2020BlueChoiceBrochure available at carefirstcomfedhmo

AnHSAisatax-exemptmedicalsavingsaccount thatcanbeusedtopayforyourownmdashandyour dependentsrsquomdasheligiblemedicaldentalandvision expensesWewilldepositaportionofyour premiuminyourHSAeachmonthandyoucan contributeadditionalfundstoyourHSAuptothe IRSlimits

With an HRA we fund your account to cover health carecostsbeforethedeductiblehasbeenmet HRAsprovidetax-freereimbursementforout-of-pocketmedicalexpensesWhenyouneedtomake awithdrawalyoudonotpaytaxesifyouuseitto covereligibleexpenses

Value of the HealthyBlue Advantagemdash HDHP Option (HSA) Reduceyourtaxesmdashyoupaynotaxes

oncontributionsinterestearningsor withdrawalsforeligibleexpenses

YourHSAmoneygrowstax-freeovertime

YourHSAfundsrolloverfromyeartoyear touseonfutureeligibleexpensesincluding retireehealthexpenses

WhenyourHSAbalanceexceeds$1000 youhavetheoptiontoinvestthosefunds Earningsontheseinvestmentsarealsotax freeaslongaswithdrawalsareusedfor eligibleexpenses

Ifyouare55orolderyoucanmake additionalcontributionstoyourHSA (maximumasallowedbytheInternal RevenueService(IRS)

Eligiblehealthexpensesinclude medicalprescriptiondentaland visionexpenses

enspFederal Employees Health Benefits Programenspensp2020 Health Benefit Options carefirstcomfedhmo

7

BEFORE YOU DECIDE

How an HSA works

How HSAs and HRAs work WithanHSAyouareeligibleforapremium

pass-throughamountWecontribute$75per monthforSelfand$150permonthforSelf+ OneandFamilytoyourHSA

Youmayalsocontributeadditionalamounts uptothemaximumannuallimitof$3550 forindividualsand$7100forcouplesand familiesasallowedbytheIRS

AconvenientBlueFunddebitcardgives youquickandeasyaccesstoyour HSAfunds

YoucanuseyourHSAtopayforany eligible out-of-pocket health care expensesOncetheannualdeductibleis met($1400forSelf$2800forSelf+One andFamily)CareFirstwillbegintoprovide benefitsforcoveredservices

WefundyourHRAaccount$900forSelfand $1800forSelf+OneandFamily

In-networkpreventivecareiscoveredinfull andnotsubjecttothedeductibleOnceyou meetyourdeductibleCareFirstbeginstopay forcoveredservices

WithbothHSAsandHRAsyourhealth careaccountcanonlybeusedforeligible medicalexpenses

CareFirst contribution Your deposit 100 tax-free

Use the HSA for

Medical dental and vision expenses

Prescription drugs

OR

Save it Your unspent money rolls over year after year

Sampleeligibleexpensesinclude doctorandhospitalvisitscopays eyeglassesprescriptionsandpremiums forlong-termcareinsuranceSeethe IRSlistofeligibleexpensesatirsgov

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp carefirstcomfedhmo

8

What Plan is for Me Health insurance concerns can vary from person to person While one family may need in-network coverage nationally or even worldwide (consider the HealthyBlue Advantagemdash HDHP Option) another may want coverage just regionally The examples below can help you decide what plan is right for you

Meet Michael 48yearsoldmarriedfour

dependent children between theagesof16and23

Michaelrsquosoldestchildisawayatcollege andthefamilyleadsanactiveand healthylifestyle

Thefamilyvisitsprovidersforboth preventivewellvisitsandsickvisitsand theyusethehealthcaresysteminand outsideoftheCareFirstservicearea

MichaelisconsideringtheHealthyBlue AdvantagemdashHDHP Optionbecausethisplan providesin-networkcoveragenationwide AlsothisplancanbepairedwithanHSA whichprovidestaxsavingswhenMichael usesHSAfundsforcurrentmedicalbillsmdashor evensavesforfuturemedicalexpenses

Meet Grace

60yearsoldmarried nodependents

Usesaprimarycareprovider (PCP)andspecialistsintheCareFirst serviceareaandvisitsthemoften

Wantstoaccesscarewithoutalotof out-of-pocketcosts

GraceisconsideringtheHealthyBlue Standard Optionbecausethereisno deductibleandshewillhavelowout-of-pocketcostswhensheusestheBlueChoice networkWithbothin-networkandout-of-networkcoverageGracehasthefreedom to choose

Meet Bryce

25yearsoldsingle nodependents

Likestotravel Usesthehealthcaresystemforwell

visits

BryceisconsideringtheHealthyBlue AdvantagemdashHDHP Optionforalowpremium Helikesknowingthatwhenhestaysin-networkhiswellvisitsarecovered100before hisdeductibleandthathecanfindin-network providersnationwide

Meet Jennifer

30yearsoldmarriedtwo dependentchildrenages 2and4

Familystayslocal Thefamilyusesgenericprescription

drugsandeachfamilymemberhasa PCPintheCareFirstservicearea

With two young children to care for Jennifer likesthesimplicityofaplanwithnomedicalor genericprescriptiondeductibleAgoodchoice forJenniferistheBlue Value Plus OptionThe familywillbenefitfromin-networkcoverage andpeaceofmindknowingshouldthey decidetotraveltheirurgentemergencycare is covered

The CareFirst Service Area is defined as Washington DC Maryland and Northern Virginia

Theseexamplesareprovidedtogiveyouadditionalinformationandarenottoinfluenceyourdecisions AHealthSavingsAccount(HSA)isamedicalsavingsaccountthatenablesyoutoreduceyourtaxesandgrowthefundstax-freeaslongasthemoneyisusedforeligiblemedicalexpenses

enspFederal Employees Health Benefits Programenspensp2020 Health Benefit Options carefirstcomfedhmo

9

BENEFIT PLANS

Comparing PlansmdashWhatrsquos the Same CareFirst plans have been trusted by thousands of federal employees for over 80 years For 2020 CareFirst offers you three plans to choose from On pages 13ndash14 you will find an overview of benefits so you can decide what plan is right for you Before you look at what is different the below shows you what is the same for all three plans

Emergency coverage worldwide BlueCrossBlueShieldGlobalCore (GlobalCore)providesmedicalservices andaccesstohealthcareprofessionals includingdoctorsandhospitalsinnearly 200countries

Urgentemergency coverage nationwide NomatterwhichCareFirstplanyou chooseurgentemergencycarereceived anywhereintheUSiscovered

Hospital services Inpatienthospitalstays(whenyouspend thenightinthehospital)andoutpatient services(proceduresyougetwhenyou donotspendthenightinthehospital) arecovered

Away From Home Carereg program Ifyouoryourcovereddependentsplan tobeoutoftheCareFirstserviceareafor atleast90consecutivedaysyoumaybe abletosignupforAwayFromHomeCare Thisprogramprovidestemporarybenefits includingroutineservicesthroughanother BlueCrossBlueShieldHMOintheUS Thiscoverageisperfectforextendedout-of-townbusinessortravelsemestersat schoolorfamilieslivingapart

No referrals required Seeparticipatingspecialistswithoutthe hassleofgettingareferral

No charge no deductible for in-network preventive health care Adultphysicalexamsandscreenings arecoveredWell-childvisitsand immunizationsarecovered

Maternity Prenataldeliveryandpostnatalcare includinghospitalstaysarecovered

Behavioral health Mentalhealthandsubstanceusedisorder treatmentarecoveredCareFirstwill connectyouwithtrustedproviderswho willhelpyougetapersonalizedtreatment planintheappropriatesettingincluding inpatientandoutpatientcenters

Online tools and resources WhereveryouareCareFirstgivesyouthe flexibilitytomanageyourhealthcareand wellnessgoalsatcarefirstcomfedhmo

Labs X-rays specialty imaging Diagnosticservicesarecoveredif youstayin-networkOut-of-network diagnosticservicesareonlycoveredfor urgentemergencycare

Free 247 nurse advice line

Video Visit Telemedicineprovidesvirtualvisits 247365

Blue Rewards Earnfinancialrewardsforparticipatingin health-relatedactivities

ThisisnotacompletelistofallservicesForacomprehensiveexplanationofyourcoveragepleasecheckyour2020BlueChoicebrochureon ourwebsiteatcarefirstcomfedhmo

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp carefirstcomfedhmo

10

HealthyBlue AdvantagemdashHDHP Option HealthyBlue AdvantagemdashHDHP Option offers you the most flexibility and choice by providing both in-network and out-of-network coverage and in-network coverage nationwide You also have the option to pair this plan with a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) For more information on HSAs and HRAs see pages 6-7

Large provider network 44000CareFirstBlueChoiceproviders

inWashingtonDCMarylandand NorthernVirginiaThatmeans100 ofthehospitalsintheareaand99of thephysicians

Nationwideyouhaveaccessto96 ofhospitalsand95ofphysiciansso evenifyouaretravelingacrossthe USyoucanfindin-networkBlueCard PPOproviders

Where to go for lab work InsidetheCareFirstServiceArea

(MDDCNorthernVA)youmust useLabCorp

OutsidetheCareFirstService AreayoucanuseanyBlueCard PPOfacility

Benefit highlights

ThisplanhasadeductibleSomeservicesare only covered after you meet your deductible howevermanyin-networkservicesare covered even if you have not met your deductibleincluding

Earnupto$200inBlueRewards

Comprehensivepreventivehealthcarevisits

Well-childcareandimmunizations

Preventivedrugs

Afteryoumeetyourannualdeductible benefitsinclude

Prescriptionsatlowcopaysandnocharge for generics

Nochargeforin-networklabs

No charge for in-network mental health servicesreceivedindoctorrsquosoffice

Nochargeforretailhealthcenters(eg CVS MinuteClinic)

How HealthyBlue AdvantagemdashHDHP Option network coverage works

In-network you pay $ BlueChoice network

Out-of-network you pay $$ BlueCard PPO network

Non-participating providers you pay $$$ (Balance billing may apply)

When you receive care inside the CareFirst BlueChoice service area

In-network you pay $ BlueCard PPO network

Non-participating providers you pay $$$ (Balance billing may apply)

When you receive care outside the CareFirst BlueChoice service area

ThisisnotacompletelistofallservicesForacomprehensiveexplanationofyourcoveragepleasecheckyour2020BlueChoicebrochureon ourwebsiteatcarefirstcomfedhmo

enspFederal Employees Health Benefits Programenspensp2020 Health Benefit Options

carefirstcomfedhmo

Blue Value Plus Option our NEW plan Wersquore excited to offer a new plan along with our existing HDHP Option and Standard Option plans Itrsquos called Blue Value Plus This plan is an in-network only HMO and you must use an in-network provider With Blue Value Plus you and your primary care provider (PCP) are in control Your PCP will provide routine care and help coordinate specialty care however you do not need a referral to visit a specialist

Large provider network 44000CareFirstBlueChoice providersinWashingtonDC MarylandandNorthernVirginia Thatmeans100ofthehospitalsin theareaand99ofthephysicians

Urgentemergencyservices coverednationwide

Where to go for lab work InsidetheCareFirstServiceArea

(MDDCNorthernVA)youmust useLabCorp

LabworkoutsidetheCareFirst ServiceAreaisnotcoveredexcept forurgentemergencycare

Benefit highlights

No medical deductible

Nochargeforcomprehensivepreventive healthcarevisits

$10officevisitcopayatyourPCP

$10copayforVideoVisit(telehealthPCPvisits)

$10copayforgenericprescriptions

Earnupto$200inBlueRewards

How Blue Value Plus Option network coverage works

ThisisnotacompletelistofallservicesForacomprehensiveexplanationofyourcoveragepleasecheckyour2020BlueChoicebrochure available at carefirstcomfedhmo

In-network you pay $ BlueChoice network

Out-of-network services are not covered except for urgentemergency care

In-network Out-of-network

BENEFIT PLANS

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp carefirstcomfedhmo 11

12

HealthyBluemdashStandard Option HealthyBluemdashStandard Option has no deductible and gives you the benefit of no out-of-pocket costs for select services while still offering you choices on where and how you get care

Large provider network 44000CareFirstBlueChoiceproviders inWashingtonDCMarylandand NorthernVirginiaThatmeans100 ofthehospitalsintheareaand99of thephysicians

Emergencyservicescovered nationwideWithaccessto96of hospitalsand95ofphysiciansifthe unexpectedhappensyouarecovered

Where to go for lab work InsidetheCareFirstServiceArea

(MDDCNorthernVA)youmust useLabCorp

LabworkoutsidetheCareFirstService Areaisnotcoveredexceptforurgent emergencycare

Benefit highlights

Nomedicalorprescriptiondeductible

Nochargeforcomprehensivein-network preventivehealthcarevisits

Nochargeforvisitstoyourprimarycare provider(PCP)includingpediatricians

Nochargeforretailhealthcenters(eg CVSMinuteClinic)

Nochargeforin-networklabs

No charge for in-network mental health servicesinadoctorrsquosoffice

Earnupto$200inBlueRewards

How HealthyBluemdashStandard Option network coverage works

In-network

Non-participating providers you pay $$$ (Balance billing may apply)

Out-of-network

In-network you pay $ BlueChoice network

Out-of-network you pay $$ BlueCard PPO network

ThisisnotacompletelistofallservicesForacomprehensiveexplanationofyourcoveragepleasecheckyour2020BlueChoicebrochure available at carefirstcomfedhmo

enspFederal Employees Health Benefits Programenspensp2020 Health Benefit Options

carefirstcomfedhmo

13

BENEFIT PLANS

In-Network Benefit Comparison

HealthyBlue Advantage HealthyBlue Standard Services Blue Value Plus Option mdashHDHP Option Option

WELLNESS PROGRAM amp BLUE REWARDS YouhaveaccesstoacomprehensivewellnessprogramaspartofyourmedicalplanYoualsohave BlueRewardsanincentiveprogramwhereyoucangetrewardedforcompletingcertainactivities

ANNUAL DEDUCTIBLE

SelfOnly

Self+OneSelfandFamily

$1400 Monthlypremiumpassthrough amount$75Thisistheamount $0 $0

we put directly in your Health SavingsAccount

$2800 Monthlypremiumpassthrough

amount$150Thisisthe $0 $0 amount we put directly in your

HealthSavingsAccount ANNUAL OUT-OF-POCKET MAXIMUM

SelfOnly $4000 $5000 $2500

Self+OneSelfandFamily $6500 $10000 $5000

PREVENTIVE SERVICES Well-ChildVisitAdultPhysical $0 $0 $0 ExamRoutineGYNMaternity BreastProstateColorectal $0 $0 $0 Screening

OUTPATIENT SERVICES (Per visit or procedure)

PrimaryCareOfficeVisit Deductible$0 $10 $0

SpecialistVisit Deductible$35 $50 $40

CareFirstVideoVisit Deductible$0 $10 $0

PhysicalSpeechampOccupational Deductible$35 $50 $40 Therapy AcupunctureampChiropractic Deductible$35 $50 $40 Services URGENT amp EMERGENCY CARE

UrgentCare(pervisit) Deductible$50 $50 $50

EmergencyRoomFacility Deductible$300 $275 $200 (waivedifadmitted)

Ambulance Deductible$50 $200 $50

DIAGNOSTIC SERVICES (Non-hospitalFreestanding facility)

Labs Deductible$0 $30 $0

X-rays Deductible$35 $50 $40

SpecialtyImaging(ieMRICAT Deductible$50 $100 $60 Scan) HOSPITALIZATION (Physician fees are listed in section 5(b) of CareFirst Inc Brochure) OutpatientFreestanding Deductible$100 $150 $100 AmbulatorySurgicalCenter OutpatientHospitalSurgical Deductible$300 $200 $150 Services

InpatientHospitalServices Deductible20 25 20

Maternity Deductible20 25 20

MENTAL HEALTH AND SUBSTANCE USE DISORDER

OfficeOutpatientProfessional Deductible$0 $10 $0

This summary is for comparison purposes only amp does not create rights not given through the benefit plan Please refer to your 2020 FEHBP BlueChoice Contract for specific plan details

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp

carefirstcomfedhmo

14

Pharmacy Benefits

Services Blue Value Plus Option

Rx Deductible

PHARMACY (Retail up to a 34-day supply) Preventive Drugs ExamplesfolicacidfluorideandFDAapprovedcontraceptivesforwomen

Preferred Generic

Preferred Brand

Preferred Generic Specialty

Preferred Brand Specialty

$100SelfOnly $200Self+OneSelfandFamily

$0nodeductible

$10nodeductible

$50afterdeductible

$100afterdeductible2

$150afterdeductible2

Services HealthyBlue AdvantagemdashHDHP Option HealthyBlue Standard Option

Combinedmedicalandprescriptiondrugdeductible Rx Deductible $0 $1400SelfOnly$2800Self+OneSelfandFamily

PHARMACY (Retail up to a 34-day supply) Preventive Drugs ExamplesfolicacidfluorideandFDA approvedcontraceptivesforwomen

Generic

Preferred Brand

Non-preferred Brand

Preferred Specialty

Non-preferred Specialty

$0nodeductible

$0afterdeductible1

$30afterdeductible

$60afterdeductible

$100afterdeductible2

$150afterdeductible2

$0

$0

$35

$65

$1002

$1502

ThissummaryisforcomparisonpurposesonlyanddoesnotcreaterightsnotgiventhroughthebenefitplanPleaserefertoyour2020FEHBP BlueChoiceBrochureforspecificplandetails 1Selectgenericsnotsubjecttodeductible 2Specialtydrugslimitedto34-daysupplyforfirstfillandchangeinfillsSpecialtydrugsmustbefilledthroughCVSSpecialtyPharmacy

Manage medications and save MailorderisaconvenientoptionespeciallyforrefillingmedicationstakenfrequentlyWithourMail Service PharmacyyoursquollbeabletoRefillprescriptionsonlinebyphoneorbyemailChooseyourdeliverylocation Consultwithpharmacistsbyphone247ScheduleautomaticrefillsReceiveemailnotificationsoforder statusChoosefrommultiplepaymentoptions

Youcanreceiveupto90 daysofmaintenancemedicationsthroughourmailorderpharmacyprogramor throughalocalpharmacyandwillpaytwo(2)copaysMaintenancemedicationsaredrugsyoutakeregularly forongoingconditionssuchasdiabeteshighbloodpressureorasthmaThetieryourdrugfallsincanvary betweentheHDHPOptiontheStandardOptionandBlueValuePlusOptionPleasechecktheDrugCalculator toolandtheapproveddruglistspriortoselectingaplantomakesurewecoveryourdruginthatplan

Available on carefirstcom fedhmo under Plan Information gt Prescription Drug Benefits This tool helps you find information on covered drugs out-of-pocket drug costs and lower cost alternatives

Ask your doctor or check the online Preferred Drug List to see if there is a generic or preferred brand alternative drug available You could save by switching to a compatible generic or preferred brand (Tier 2) drug

See complete list of drugs at carefirstcomfedhmo or call 800-241-3371

enspFederal Employees Health Benefits Programenspensp2020 Health Benefit Options

enspDrug Calculator Tool enspSaving Tips enspDrug List

carefirstcomfedhmo

15

WITH EVERY PLAN

Health and Wellness CareFirst BlueChoice Inc partners with Sharecare to provide you a unique highly personalized wellness program

Take charge of your health

Seeifyourhealthyhabitsaremakinganimpactmdash

taketheRealAgereghealthassessmentInjusta fewminutesRealAgewillhelpyoudetermine thephysicalageofyourbodycomparedtoyour calendarageDiscoverthelifestylebehaviorshelping youstayyoungerormakingyouagefasterandget insightfulrecommendationsbasedonyourresults

Exclusive features Ourwellnessprogramhastailoredresources andtoolsthatreflectyourownpreferencesand interestsincluding

Personalized timeline Receivecustomized contentbasedonyourhealthgoalsmotivation andinterests

Trackers Connectwearabledevicesto monitordailyhabitslikesleepstepsnutrition andmore

Challenges Needhelpstayingmotivated Join a challenge to make achieving your health goalsmoreentertaining

Health profiles Accessimportanthealth data like your biometric information vaccinehistorylabresultsandmedicationsallin oneplace

Togetstartedvisitcarefirstcom sharecareYoursquollneedtoenteryour CareFirstMy Accountusernameand passwordandcompletetheone-time registrationwithSharecaretolinkyour CareFirstaccountinformationThiswill helppersonalizeyourexperienceIf youhavenotregisteredforCareFirst My Accountfollowthescreenprompts toregister

Additional program advantages Blue Rewards incentive programmdashEarn

financialincentivesforparticipatingin healthyactivitiesandconsentingtoreceive wellnessemails

Wellness discount programmdashSignupfor Blue365atcarefirstcomwellnessdiscounts Getspecialoffersfromtopnationalandlocal retailersonfitnessgeargymmemberships healthyeatingandmore

Vitality magazinemdashRead our member magazinewhichincludesimportantplan information at carefirstcomvitality

Health educationmdashViewourhealthlibrary for health and well-being information at carefirstcomlivinghealthy

Specialized programs

Thefollowingprogramscanhelpyoufocuson specificwellnessgoals

Health coachingmdashCoachesareregistered nursesandtrainedprofessionalswhoprovide one-on-onesupporttohelpyoureachyour wellnessgoals

Weight management programmdashReach a healthierweightthroughgraduallifestyle changesthatbecomelifelonghabits

Tobacco cessation programmdashOurprogramrsquos expertguidancesupportandwealthoftools makequittingeasier

Financial well-being programmdashWhether you areplanningforyourchildrsquoseducationyour ownretirementorjustwanttoimproveyour currentsituationourfinancialwell-being programcanhelp

SharecareIncisanindependentcompanythatprovideshealthimprovementmanagementservicestoCareFirstmembersSharecareInc doesnotprovideCareFirstBlueChoiceIncproductsorservicesandissolelyresponsibleforthehealthimprovementmanagementservicesit provides

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp carefirstcomfedhmo

16

Blue Rewards Our Blue Rewards incentive program gives you the flexibility to choose which healthy activities interest you the most and be rewarded for completing them

How Blue Rewards works

Bothyouandyourspousedomesticpartnercaneachearnincentivesforcompletingoneorallofthe followingactivities

Earn $50 Consent to receive wellness emails and take the RealAgereg test

TheRealAgetestisasimple questionnairethatwillhelpyou determinethephysicalageof your body compared to your calendarage

Must complete within 120 days of your effective date

Earn $100 Select a PCMH or PCMH Plus primary care provider (PCP) and complete a health screening

YoucanvisityourPCPorCVS MinuteClinictocompleteyour screening

Must complete within 120 days of your effective date

Earn $50 Retake the RealAge test

Ifyouearnedtherewardfortaking thetestinitiallyyoucanearnan additional reward for retaking it aftersixmonths

Must complete before end of calendar year

Choosing a PCP

BesuretochooseaPCPwhoparticipatesinour Patient-CenteredMedicalHome(PCMH)orPCMH PlusprogramtoearnyourrewardThePCMH programisdesignedtoprovideyourPCPwitha morecompleteviewofyourhealthneedsandthe careyoureceivefromourproviders

Health screening

Healthscreeningshelpyouunderstandyour currenthealthstatussoyoucantakestepsto improveit

Your CareFirst Blue Rewards Visareg incentive card

Afteryoucompleteoneormoreoftheactivities yoursquollgetyourincentivecardrewardin10-14 daysIfyouhaveanHSAplanwithHealthyBlue

AdvantagemdashHDHPOptionyoumustagreetothe HSAAgreementTermsinyourSharecareaccount beforerewardscanbeearned

Yourincentivecardcanbeusedtowardyour out-of-pocketcostsrelatedtoeligibleexpenses (medicalprescriptiondrugdentalandvision) underyourCareFirsthealthplanSaveyour receiptsasproofofyourexpense

KeepyourcardaslongasyouareaCareFirst memberFutureincentivesyouearnwillbe automaticallyaddedtothesamecard

UseyourrewardbyendofcalendaryearYou willhave90daysfromendofyeartoreimburse yourselfforeligibleexpensesthatoccurredinthat calendaryear

IfyouhaveHealthyBlueAdvantagemdashHDHPOptionandyouliveoutsideMDDCorNorthernVAyoucanselectaproviderfromthe BlueCardregPPOnetworkwhospecializesingeneralpracticefamilypracticeinternalmedicinepediatricsorgeriatrics ThepolicyholderisresponsibleforloggingintotheirSharecareaccountandacceptingtheHSAAgreementTerms NOTEMembersthatweidentifyforcoachingareeligibletoearnuptoanadditional$200rewardThoseidentifiedwillbenotifiedwith additionalinformation CVSMinuteClinicisanindependentcompanythatprovidesmedicalservicestoCareFirstmembersCVSMinuteClinicdoesnotprovideCareFirst BlueChoiceIncproductsorservicesandissolelyresponsibleforthemedicalservicesitprovides TheCareFirstBlueRewardsVisaIncentiveCardisissuedbyTheBancorpBankMemberFDICpursuanttoalicensefromVisaUSAInc CardsmaybeusedonlyatmerchantsintheUSandDistrictofColumbiawhereverVisadebitcardsareacceptedforeligibleexpensesSee CardholderAgreementfordetails

enspFederal Employees Health Benefits Programenspensp2020 Health Benefit Options carefirstcomfedhmo

17

WITH EVERY PLAN

Vision and Discount Dental Coverage

BlueVision

Professionalvisionservicesincludingroutine eyeexamsanddiscountedpricesoneyeglasses andcontactlensesarecoveredbyCareFirst BlueChoicethroughtheDavisVisionIncnational networkofprovidersBlueVisionisofferedaspart ofyourCareFirstBlueChoicemedicalcoverage

BlueVision Plus Plan In-Network You Pay

Eye Exam

Frames

ContactLenses(initial supply)

SpectacleLenses

$10

Pricedupto$70retail$40Pricedabove$70retail$40plus 90oftheamountover$70

Conventional80ofretailprice Disposable90ofretailprice Evaluationandfitting85of retail price

Single$35Bifocal$55 Trifocal$65Lenticular$110

Routineeyeexamsnotonlykeepyoureyes healthytheycandetectotherhealthissuessuch asdiabetesbeforesymptomsoccurBlueVision makeseyehealtheasywithalargenetworkof optometristsophthalmologistsandopticians fromwhichtochooseTofindaparticipating providersearchouronlineproviderdirectoryat carefirstcomfedhmo

NeedmoreinformationPleasevisit carefirstcomfedhmo or call 888-789-9065

DavisVisionIncisanindependentcompanythatprovidesvisionservicestoCareFirstBlueCrossBlueShieldandCareFirst BlueChoice membersDavisVisiondoesnotprovideBlueCrossBlueShieldproductsorservices CareFirstBlueChoicedoesnotunderwritelensesframesandcontactlensesinthisprogramThisportionoftheplanisnotaninsurance productAsof4114someprovidersinMarylandandVirginiamaynolongerprovidethesediscounts

BlueChoice Discount Dental Program

Save20-40offmostdentalprocedures includingroutineofficevisitsX-raysexams fillingsrootcanalsandevenorthodonticsThe BlueChoiceDiscountDentalprogramisincluded atnoadditionalchargeaspartofyourCareFirst BlueChoicemedicalplanandisadministeredby TheDentalNetworkanindependentlicenseeof theBlueCrossandBlueShieldAssociation

ThereisnoseparatedentalIDcardTogetyour dentalservicesatdiscountedfeessimplypresent yourBlueChoicememberIDcardwhenyouvisit anyparticipatingproviderTherearenoclaim formsnomaximumsandnodeductiblesTofind aparticipatingprovidersearchouronlineprovider directory at carefirstcomfedhmo

Ifyouhavequestionsregardingthediscountdental programpleasecall844-495-0653

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp carefirstcomfedhmo

18

Behavioral Health and Addiction Support Livingyourbestlifeinvolvesgoodphysicaland mentalhealthAmindateaseisimportantateverystageinlifefromadolescencethroughadulthood Itrsquoscommontofacesomeformofmentalhealth challengeduringyourlifeTheseissuescanstem fromavarietyofreasonsmanyofwhichare beyondyourcontrol

Ifmentalhealthdifficultiesariseforyouorafamily memberyouarenotaloneandfeelingbetteris achievableCareFirstBlueChoiceInc(CareFirst)is heretohelpWeprovideassistancerelatedto

Depression

Drugoralcohol dependence

Anxiety

Stress

Work-life balance Eatingdisorders

AsaCareFirstmemberyouhaveaccesstospecially trainedservicerepresentativesregisterednurses andlicensedbehavioralhealthcliniciansreadyto

Helpyoufindtherightmentalhealth provider(s)andscheduleappointments

Connectyouwithacarecoordinatorwho will work with your doctor to create a tailored action plan

Findsupportgroupsandresourcestohelp youstayontrack

Substance use disorder support

Ifyouarestrugglingwithdrugoralcoholaddiction CareFirstcanhelpyougettreatmentWewill connectyoutotrustedproviderswithinrecovery centerswhowill

Providepersonalizedtreatmentinan appropriatecaresetting

Connectyouwithcounselorswhohelpyou overcomedailytemptationsandtriggers

Educateyouandyourdoctorsoncausesand symptomsofaddictionalongwithtreatment options

Save on mental health and substance use disorder office visits

Withallofourplansyougetin-networkcoverage formentalhealthandsubstanceusedisorder officevisitsonlywhenyouseeadoctoraffiliated withthebehavioralhealthnetworkOut-of-network coverageisavailablewithHealthyBlueAdvantagemdash

HDHPandHealthyBlueStandardplansTosearch online go to carefirstcomfedhmoselectFind a Provider and Search by PlanselectBehavioral Mental Health under Type of Provider

If you are in crisis help is available 247 at 800-245-7013

Ifyouorafamilymember needssupportorhelp making an appointment call800-245-7013orvisit carefirstcommentalhealth

enspFederal Employees Health Benefits Programenspensp2020 Health Benefit Options

carefirstcomfedhmo

19

WITH EVERY PLAN

BlueCard amp BlueCross BlueShield Global Core Coverageisprovidedforurgentandemergency carerenderedoutsideoftheCareFirstservice areaforallourplansHealthyBlueStandard OptionandHealthyBlueAdvantagemdashHDHP Optionprovidecoveragefornon-emergency careoutsidetheCareFirstserviceareaIfyou choosetheHealthyBlueAdvantagemdashHDHPOption ortheHealthyBlueStandardOptionyouare automaticallyenrolledintheBlueCardprogram

BlueCard

BlueCardgivesyouthepeaceofmindthatyoursquoll alwayshavethecareyouneedwhenyoursquoreaway fromhome

Morethan92ofallprovidersandhospitals throughouttheUnitedStatescontractwith Blue CrossBlue ShieldAssociationplansWithyour memberIDcardyouhaveaccesstoprovidersand hospitalsalmostanywhere

Within the United States

1 AlwayscarryyourcurrentmemberIDcard foreasyreferenceandaccesstoservices

2 Tofindnamesandaddressesof nearbyprovidersandhospitalsvisit carefirstcomfedhmoor callBlueCard Accessat800-810-BLUE(2583)

3 CallMemberServicesforprecertification orpriorauthorizationifnecessaryRefer tothephonenumberonyourmemberID cardbecauseitrsquosdifferentfromtheBlueCard AccessnumberlistedinStep2

4 PresentyourmemberIDcardwhenyou arriveattheparticipatingproviderrsquosoffice

5 Youshouldnothavetocompleteanyclaim formsorpayupfrontformedicalservices otherthantheusualout-of-pocketexpenses CareFirstBlueChoicewillsendyouacomplete ExplanationofBenefits (EOB)

Global Core

Justlikeyourpassportyoushouldalwayscarry yourCareFirstmemberIDcardwhenyoutravel outsidetheUnitedStatesTheGlobalCore programprovidesmedicalassistanceservicesand accesstoprovidershospitalsandotherhealthcare professionalsinnearly200countries

The process is the same as if you were in the United States with the following exceptions InmostcasesatGlobalCorehospitalsyou

shouldnrsquothavetopayupfrontforinpatient careandthehospitalshouldsubmityour claimYouareresponsiblefortheusualout-of-pocket expenses

Atnon-GlobalCorehospitalsyoupaythe providerorhospitalforinpatientcare outpatienthospitalcareandothermedical servicesTobereimbursedyoursquollneed to complete an international claim form andsendittotheGlobalCoreService CenterTheclaimformisavailableonlineat bcbsglobalcorecom

TofindaBlueCardprovideroutsidethe UnitedStatesvisitbcbscomselectFind a Doctor or Hospital

Medical assistance when outside the United States

Call800-810-BLUE(2583)247forinformationon doctorshospitalsotherhealthcareprofessionals ortoreceivemedicalassistanceservicesAmedicalassistancevendorinconjunctionwithamedical professionalwillmakeanappointmentwitha providerorarrangehospitalizationifnecessary

BlueCross BlueShield Global Core mobile app

With theGlobalCoremobileappyouhavehelpin thepalmofyourhandandconvenientaccessto doctorshospitalsandresourcesaroundtheworld Ataglanceyoucanfinddoctorstranslatemedical termsandaccesslocalemergencyinformation bcbsglobalcorecomhomemobileapp

BlueCrossBlueShieldGlobalisabrandownedbyBlueCrossBlueShieldAssociation

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp carefirstcomfedhmo

20

Member Services My Account Viewawealthofpersonalizedinformationon yourclaimsandout-of-pocketcostsonline with My AccountForyourconvenienceyoucan evenprintoutyourmemberIDcardSimply log in to carefirstcommyaccount from your computertabletorsmartphoneforreal-timeplan informationtoolsandtechnologylike

Treatment Cost Estimator Getquickestimatesofyourtotaltreatment costssoyoucanplanaheadsavemoneyand avoidsurprises

Drug Pricing Tool YoucanaccessourDrug Pricing Tool through My AccountThetoolallowsmembersto checkprescriptioncostsandcompare alternativesAllyouneedtoknowisthedrug nameprescribeddosageandthenameofa pharmacynearyouInsecondsyouwillknow howmuchyouhaveto pay

Electronic communications Securelyreceiveplan-relatedinformationand announcementsassoonastheybecome availablebysigningupforelectronic communicationsfromCareFirstGoto carefirstcommyaccount and click on your nametoshowdrop-downmenuSelect Electronic Consent thenchoosethe information you would like to receive electronically

Find and review providers Whetheryouneedadoctororafacilityvisit My Accounttofindwhatyoursquorelookingfor basedonyourspecificneedsYoucanalso readandsubmitproviderreviews

CareFirst Video Visit

Register todaymdashyoursquoll be ready when you need care

Visit carefirstvideovisitcom and click on any of the Video Visit links or download the CareFirst Video Visit app from your favorite app store

Consult a board-certified doctor on your smartphone tablet or computer 247365 Doctors can treat common health issues like flu and sinus infections If medication is needed prescriptions may be filled at a nearby pharmacy

Free 247 Nurse Advice Line

Call 800-535-9700 to speak to a registered nurse about your symptoms and get recommendation on the most appropriate care

CareFirst mobile access

KeepuswithyouwhereveryougoBoththe CareFirstmobilewebsiteandfreeCareFirstmobile appplacetheinformationyouneedjustatapor swipeawayTheyalsoletyouaccessyourclaims informationsearchdrugpricesviewyourIDcard and take a more active role in managing your careYoucanalsofindadoctororurgentcare centerwhenyouneedonefastOptimizedfor smartphonesandtabletsyoursquollfindtheCareFirst appinyourfavoriteappstoremdashjustdo asearchfor CareFirstandyoursquollbeset

Staying connected

Wersquove been committed to being an active part of yourcommunityformorethan50yearsandthat includestheonlinecommunitieswhereyouspend timeJoinourFacebookfollowersandcontribute toourvibrantTwittercommunitytogetthelatest informationonhealthcarereformhealthyrecipes wellnesstipsfitnesschallengesandgreatprizesmdash

directlytoyournewsfeedCheckoutourvideoson YouTubewherewediscusstopicslikeinsurance updatesanddefineusefulterms

enspFederal Employees Health Benefits Programenspensp2020 Health Benefit Options carefirstcomfedhmo

21

MEMBER SERVICES

Important Numbers and Contact Information

Global Core 800-810-BLUE(2583)

LabCorp 888-LAB-CORP(522-2677)

CareFirst Video Visit

Registertodayandyouwillbereadywhenyouneedcare

1 Visitcarefirstvideovisitcom and click onanyoftheVideoVisitlinksor

2 DownloadtheCareFirstVideoVisitapp fromyourfavoriteappstore

Federal Employees Health Benefits Programenspensp2020 Health Benefit Optionsensp

Member Services 888-789-9065

Away From Home Carereg 888-452-6403

Blue365 855-511-BLUE(2583)

Dental CoveragemdashTheDentalNetwork 888-833-8464

247 Nurse Advice Line 800-535-9700

Health amp Wellness ProgrammdashSharecare 877-260-3253

Mental Health 800-245-7013

Prescription Drug CoveragemdashCVS Caremark800-241-3371

Vision CoveragemdashDavisVision 800-783-5602

carefirstcomfedhmo

Notice of Nondiscrimination and Availability of Language Assistance Services(UPDATED 8519)

CareFirst BlueCross BlueShield CareFirst BlueChoice Inc CareFirst Diversified Benefits and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race color national origin age disability or sex CareFirst does not exclude people or treat them differently because of race color national origin age disability or sex

CareFirst

Provides free aid and services to people with disabilities to communicate effectively with us such asQualified sign language interpretersWritten information in other formats (large print audio accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such asQualified interpretersInformation written in other languages

If you need these services please call 855-258-6518

If you believe CareFirst has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our CareFirst Civil Rights Coordinator by mail fax or email If you need help filing a grievance our CareFirst Civil Rights Coordinator is available to help you

To file a grievance regarding a violation of federal civil rights please contact the Civil Rights Coordinator as indicated below Please do not send payments claims issues or other documentation to this office

Civil Rights Coordinator Corporate Office of Civil RightsMailing Address PO Box 8894 Baltimore Maryland 21224

Email Address civilrightscoordinatorcarefirstcom

Telephone Number 410-528-7820 Fax Number 410-505-2011

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 800-368-1019 800-537-7697 (TDD)

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland Inc and Group Hospitalization and Medical Services Inc CareFirst of Maryland Inc Group Hospitalization and Medical Services Inc CareFirst BlueChoice Inc The Dental Network and First Care Inc are independent licensees of the Blue Cross and Blue Shield Association In the District of Columbia and Maryland CareFirst MedPlus is the business name of First Care Inc In Virginia CareFirst MedPlus is the business name of First Care Inc of Maryland (used in VA by First Care Inc) The Blue Crossreg and Blue Shieldreg and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans

Foreign Language Assistance Attention (English) This notice contains information about your insurance coverage It may contain key dates

and you may need to take action by certain deadlines You have the right to get this information and assistance in

your language at no cost Members should call the phone number on the back of their member identification card

All others may call 855-258-6518 and wait through the dialogue until prompted to push 0 When an agent

answers state the language you need and you will be connected to an interpreter

አማርኛ (Amharic) ማሳሰቢያ ይህ ማስታወቂያ ስለ መድን ሽፋንዎ መረጃ ይዟል ከተወሰኑ ቀነ-ገደቦች በፊት ሊፈጽሟቸው የሚገቡ ነገሮች ሊኖሩ ስለሚችሉ እነዚህን ወሳኝ ቀናት ሊይዝ ይችላል ይኽን መረጃ የማግኘት እና ያለምንም ክፍያ በቋንቋዎ እገዛ የማግኘት መብት አለዎት አባል ከሆኑ ከመታወቂያ ካርድዎ በስተጀርባ ላይ ወደተጠቀሰው የስልክ ቁጥር መደወል ይችላሉ አባል ካልሆኑ ደግሞ ወደ ስልክ ቁጥር

855-258-6518 ደውለው 0ን እንዲጫኑ እስኪነገርዎ ድረስ ንግግሩን መጠበቅ አለብዎ አንድ ወኪል መልስ ሲሰጥዎ የሚፈልጉትን ቋንቋ ያሳውቁ ከዚያም ከተርጓሚ ጋር ይገናኛሉ

Egravedegrave Yorugravebaacute (Yoruba) Igravetẹtiacuteleacuteko Agravekiacuteyegravesiacute yigraveiacute niacute igravewiacutefuacuten niacutepa iṣẹ adoacutejuacutetogravefograve rẹ Oacute le niacute agravewọn deacuteegravetigrave pagravetoacute o sigrave le niacute laacuteti

gbeacute igravegbeacutesẹ niacute agravewọn ọjọ gbegravedeacuteke kan O ni ẹtọ laacuteti gba igravewiacutefuacuten yigraveiacute agraveti igraveragravenlọwọ niacute egravedegrave rẹ lọfẹẹ Agravewọn ọmọ-ẹgbẹ

gbọdọ pe nọmbagrave foacuteogravenugrave toacute wagrave lẹyigraven kaacuteagravedigrave igravedaacutenimọ wọn Agravewọn miacuteragraven le pe 855-258-6518 kiacute o sigrave duacuteroacute niacutepasẹ igravejiacuterograverograve

tiacutetiacute a oacute fi sọ fuacuten ọ laacuteti tẹ 0 Niacutegbagravetiacute aṣojuacute kan baacute daacutehugraven sọ egravedegrave tiacute o fẹ a oacute sigrave so ọ pọ mọ ogravegbufọ kan

Tiếng Việt (Vietnamese) Chuacute yacute Thocircng baacuteo nagravey chứa thocircng tin về phạm vi bảo hiểm của quyacute vị Thocircng baacuteo coacute thể

chứa những ngagravey quan trọng vagrave quyacute vị cần hagravenh động trước một số thời hạn nhất định Quyacute vị coacute quyền nhận

được thocircng tin nagravey vagrave hỗ trợ bằng ngocircn ngữ của quyacute vị hoagraven toagraven miễn phiacute Caacutec thagravenh viecircn necircn gọi số điện thoại

ở mặt sau của thẻ nhận dạng Tất cả những người khaacutec coacute thể gọi số 855-258-6518 vagrave chờ hết cuộc đối thoại cho

đến khi được nhắc nhấn phiacutem 0 Khi một tổng đagravei viecircn trả lời hatildey necircu rotilde ngocircn ngữ quyacute vị cần vagrave quyacute vị sẽ được

kết nối với một thocircng dịch viecircn

Tagalog (Tagalog) Atensyon Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong

insurance Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng

aksyon ayon sa ilang deadline May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling

wika nang walang gastos Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang

identification card Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng

diyalogo hanggang sa diktahan na pindutin ang 0 Kapag sumagot ang ahente sabihin ang wika na kailangan mo

at ikokonekta ka sa isang interpreter

Espantildeol (Spanish) Atencioacuten Este aviso contiene informacioacuten sobre su cobertura de seguro Es posible que

incluya fechas clave y que usted tenga que realizar alguna accioacuten antes de ciertas fechas liacutemite Usted tiene

derecho a obtener esta informacioacuten y asistencia en su idioma sin ninguacuten costo Los asegurados deben llamar al

nuacutemero de teleacutefono que se encuentra al reverso de su tarjeta de identificacioacuten Todos los demaacutes pueden llamar al

855-258-6518 y esperar la grabacioacuten hasta que se les indique que deben presionar 0 Cuando un agente de seguros

responda indique el idioma que necesita y se le comunicaraacute con un inteacuterprete

Русский (Russian) Внимание Настоящее уведомление содержит информацию о вашем страховом

обеспечении В нем могут указываться важные даты и от вас может потребоваться выполнить некоторые

действия до определенного срока Вы имеете право бесплатно получить настоящие сведения и

сопутствующую помощь на удобном вам языке Участникам следует обращаться по номеру телефона

указанному на тыльной стороне идентификационной карты Все прочие абоненты могут звонить по

номеру 855-258-6518 и ожидать пока в голосовом меню не будет предложено нажать цифру laquo0raquo При

ответе агента укажите желаемый язык общения и вас свяжут с переводчиком

हिनदी (Hindi) धयान द इस सचना म आपकी बीमा कवरज क बार म जानकारी दी गई ि िो सकता ि कक इसम मखय

ततथियो का उललख िो और आपक ललए ककसी तनयत समय-सीमा क भीतर काम करना जररी िो आपको यि जानकारी और सबथित सिायता अपनी भाषा म तनिःशलक पान का अथिकार ि सदसयो को अपन पिचान पतर क पीछ हदए गए फोन

नबर पर कॉल करना चाहिए अनय सभी लोग 855-258-6518 पर कॉल कर सकत ि और जब तक 0 दबान क ललए न किा जाए तब तक सवाद की परतीकषा कर जब कोई एजट उततर द तो उस अपनी भाषा बताए और आपको वयाखयाकार स कनकट

कर हदया जाएगा

Ɓǎsɔɔ-wugraveɖugrave (Bassa) To Ɖuu Cao Bɔ nia kɛ ɓa nyɔ ɓe ke m gbo kpa ɓo ni fu a-fũa-tiin nyɛɛ je dyi Bɔ nia kɛ

ɓeɖe we jɛɛ ɓe ɓɛ m ke ɖɛ wa mɔ m ke nyuɛɛ nyu hwɛ ɓɛ we ɓea ke zi Ɔ mɔ ni kpe ɓɛ m ke bɔ nia kɛ ke gbo-

kpa-kpa m mɔɛɛ dye ɖe ni ɓiɖi-wuɖu mu ɓɛ m ke se wiɖi ɖo pɛɛ Kpooɔ nyɔ ɓe mɛ ɖa fũugraven-nɔɓa nia ɖe waa

ID kaaɔ ɖein nyɛ Nyɔ tɔɔ sein mɛ ɖa nɔɓa nia kɛ 855-258-6518 ke m mɛ fo tee ɓɛ wa keɛ m gbo cɛ ɓɛ m ke

nɔɓa mɔa 0 kɛɛ dyi paɖain hwɛ Ɔ ju ke nyɔ ɖo dyi m gɔ juin po wuɖu m mɔ poɛ dyiɛ ke nyɔ ɖo mu ɓo niin

ɓɛ ɔ ke ni wuɖuɔ mu za

বাাংলা (Bengali) লকষয করন এই ননাটিশে আপনার ববমা কভাশরজ সমপশকে তথয রশেশে এর মশযয গরতবপরে তাবরখ থাকশত পাশর

এবাং বনবদেষট তাবরশখর মশযয আপনাশক পদশকষপ বনশত হশত পাশর ববনা খরশে বনশজর ভাষাে এই তথয পাওোর এবাং সহােতা পাওোর

অবযকার আপনার আশে সদসযশদরশক তাশদর পবরেেপশের বপেশন থাকা নমবশর কল করশত হশব অশনযরা 855-258-6518 নমবশর

কল কশর 0 টিপশত না বলা পরেনত অশপকষা করশত পাশরন রখন নকাশনা এশজনট উততর নদশবন তখন আপনার বনশজর ভাষার নাম বলন

এবাং আপনাশক নদাভাষীর সশে সাংরকত করা হশব

یہ نوٹس آپ کے انشورینس کوریج سے متعلق معلومات پر مشتمل ہے اس میں کلیدی تاریخیں ہو سکتی ہیں اور ممکن توجہ (Urduاردو )

ہے کہ آپ کو مخصوص آخری تاریخوں تک کارروائی کرنے کی ضرورت پڑے آپ کے پاس یہ معلومات حاصل کرنے اور بغیر خرچہ

کو اپنے شناختی کارڈ کی پشت پر موجود فون نمبر پر کال کرنی چاہیے سبھی دیگر کیے اپنی زبان میں مدد حاصل کرنے کا حق ہے ممبران

دبانے کو کہے جانے تک انتظار کریں ایجنٹ کے جواب دینے پر اپنی مطلوبہ زبان 0پر کال کر سکتے ہیں اور 6518-258-855لوگ

بتائیں اور مترجم سے مربوط ہو جائیں گے

توجه این اعالمیه حاوی اطالعاتی درباره پوشش بیمه شما است ممکن است حاوی تاریخ های مھمی باشد و الزم است تا تاریخ (Farsiفارسی )

مقرر شده خاصی اقدام کنید شما از این حق برخوردار هستید تا این اطالعات و راهنمایی را به صورت رایگان به زبان خودتان دریافت کنید

شان تماس بگیرند سایر افراد می توانند با شماره ره درج شده در پشت کارت شناساییاعضا باید با شما

را فشار دهند بعد از پاسخگویی توسط یکی از اپراتورها زبان 0تماس بگیرند و منتظر بمانند تا از آنھا خواسته شود عدد 855-258-6518

مورد نیاز را تنظیم کنید تا به مترجم مربوطه وصل شوید

اتخاذ إلى تحتاج وقد مھمة تواریخ على یحتوي وقد التأمینیة تغطیتك بشأن معلومات على اإلخطار هذا یحتوي تنبیه (Arabic) العربیة اللغة

االتصال األعضاء على ینبغي تكلفة أي تحمل بدون بلغتك والمعلومات المساعدة هذه على الحصول لك یحق محددة نھائیة مواعید بحلول إجراءات

الرقم على االتصال لآلخرین یمكن بھم الخاصة الھویة تعریف بطاقة ظھر في المذكور الھاتف رقم على

بھا التواصل إلى تحتاج التي اللغة اذكر الوكالء أحد إجابة عند 0 رقم على الضغط منھم یطلب حتى المحادثة خالل واالنتظار855-258-6518

الفوریین المترجمین بأحد توصیلك وسیتم

中文繁体 (Traditional Chinese) 注意本聲明包含關於您的保險給付相關資訊本聲明可能包含重要日期

及您在特定期限之前需要採取的行動您有權利免費獲得這份資訊以及透過您的母語提供的協助服

務會員請撥打印在身分識別卡背面的電話號碼其他所有人士可撥打電話 855-258-6518並等候直到

對話提示按下按鍵 0當接線生回答時請說出您需要使用的語言這樣您就能與口譯人員連線

Igbo (Igbo) Nrụbama Ọkwa a nwere ozi gbasara mkpuchi nchekwa onwe gị Ọ nwere ike ịnwe ụbọchị ndị dị

mkpa ị nwere ike ịme ihe tupu ụfọdụ ụbọchị njedebe Ị nwere ikike ịnweta ozi na enyemaka a nrsquoasụsụ gị na

akwụghị ụgwọ ọ bụla Ndị otu kwesịrị ịkpọ akara ekwentị dị nrsquoazụ nke kaadị njirimara ha Ndị ọzọ niile nwere

ike ịkpọ 855-258-6518 wee chere ụbụbọ ahụ ruo mgbe amanyere ịpị 0 Mgbe onye nnọchite anya zara kwuo

asụsụ ị chọrọ a ga-ejikọ gị na onye ọkọwa okwu

Deutsch (German) Achtung Diese Mitteilung enthaumllt Informationen uumlber Ihren Versicherungsschutz Sie kann

wichtige Termine beinhalten und Sie muumlssen gegebenenfalls innerhalb bestimmter Fristen reagieren Sie haben

das Recht diese Informationen und weitere Unterstuumltzung kostenlos in Ihrer Sprache zu erhalten Als Mitglied

verwenden Sie bitte die auf der Ruumlckseite Ihrer Karte angegebene Telefonnummer Alle anderen Personen rufen

bitte die Nummer 855-258-6518 an und warten auf die Aufforderung die Taste 0 zu druumlcken Geben Sie dem

Mitarbeiter die gewuumlnschte Sprache an damit er Sie mit einem Dolmetscher verbinden kann

Franccedilais (French) Attention cet avis contient des informations sur votre couverture dassurance Des dates

importantes peuvent y figurer et il se peut que vous deviez entreprendre des deacutemarches avant certaines eacutecheacuteances

Vous avez le droit dobtenir gratuitement ces informations et de laide dans votre langue Les membres doivent

appeler le numeacutero de teacuteleacutephone figurant agrave larriegravere de leur carte didentification Tous les autres peuvent appeler le

855-258-6518 et apregraves avoir eacutecouteacute le message appuyer sur le 0 lorsquils seront inviteacutes agrave le faire Lorsquun(e)

employeacute(e) reacutepondra indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interpregravete

한국어(Korean) 주의 이 통지서에는 보험 커버리지에 대한 정보가 포함되어 있습니다 주요 날짜 및

조치를 취해야 하는 특정 기한이 포함될 수 있습니다 귀하에게는 사용 언어로 해당 정보와 지원을 받을

권리가 있습니다 회원이신 경우 ID 카드의 뒷면에 있는 전화번호로 연락해 주십시오 회원이 아니신 경우

855-258-6518 번으로 전화하여 0을 누르라는 메시지가 들릴 때까지 기다리십시오 연결된 상담원에게

필요한 언어를 말씀하시면 통역 서비스에 연결해 드립니다

(Navajo)

855-258-6518

BOK5260-1S (1019)

2020 Rate Information for CareFirst BlueChoice IncTo compare your FEHB health plan options please go to opmgovfehbcompare

To review premium rates for all FEHB health plan options please go to wwwopmgovFEHBpremiums or wwwopmgovTribalpremium

Non-Postal rates apply to most non-Postal employees If you are in a special enrollment category contact the agency that maintains your health benefits enrollment

Postal rates apply to certain United States Postal Service employees as follows

Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreements APWU ITAS NALC and NPMHU

If you are a career bargaining unit employee represented by the agreement with NPPN you will find your premium rates on httpsliteblueuspsgovfehb

Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreement PPOA

Non-Postal rates apply to all career non-bargaining unit Postal Service employees and career employees represented by NRLCA agreement Postal rates do not apply to non-career Postal employees Postal retirees and associate members of any Postal employee organization who are not career Postal employees

USPS Human Resources Shared Service Center 877-477-3273 option 5 Federal Relay Service 800-877-8339

Premiums for Tribal employees are shown under the monthly non-Postal column The amount shown under employee contribution is the maximum you will pay Your Tribal employer may choose to contribute a higher portion of your premium Please contact your Tribal Benefits Officer for exact rates

Type of EnrollmentEnrollment

Code

Non-Postal Premium Postal Premium

Biweekly Monthly BiweeklyGovernment

ShareYour Share

Government Share

Your Share

Category 1 Your Share

Category 2 Your Share

HDHP Option (Self Only) B61 $19734 $6578 $42757 $14252 $6315 $5460

HDHP Option (Self + One) B63 $39467 $13156 $85513 $28504 $12630 $10919

HDHP Option (Self and Family) B62 $46887 $15629 $101588 $33863 $15004 $12972

Blue Value Plus Option (Self Only) B64 $23577 $9007 $51084 $19515 $8679 $7697

Blue Value Plus Option (Self + One) B66 $48878 $16292 $105902 $35300 $15641 $13523

Blue Value Plus Option (Self and Family)

B65 $54647 $22774 $118402 $49344 $22015 $19739

Standard Option (Self Only) 2G4 $23577 $15448 $51084 $33470 $15120 $14138

Standard Option (Self + One) 2G6 $50412 $27637 $109226 $59880 $26937 $24836

Standard Option (Self and Family) 2G5 $54647 $38074 $118402 $82494 $37315 $35039

carefirstcomfedhmo

CONNECT WITH US

CareFirst BlueChoice Inc is an independent licensee of the Blue Cross and Blue Shield Association The Blue Crossreg and Blue Shieldreg and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans