2022 BlueChoice Advantage: Fairfax County Schools Health Insurance Benefits Summary, Lecture notes of Radiology

Download 2022 BlueChoice Advantage: Fairfax County Schools Health Insurance Benefits Summary and more Lecture notes Radiology in PDF only on Docsity! CST2977-1P (9/21) BlueChoice Advantage 2022 Summary of Benefits Fairfax County Public Schools Services In-Network You Pay1 Out-of-Network You Pay1,2 Visit carefirst.com/fcps to locate providers and facilities Provider Care received by a BlueChoice, BluePreferred, or BlueCard PPO provider Care received by a non-participating provider ANNUAL DEDUCTIBLE (Benefit period) Individual $250 $500 Family $500 $1,000 ANNUAL OUT-OF-POCKET MAXIMUM (Benefit period) Medical $2,000 Individual/$4,000 Family (combined in-and out-of-network) LIFETIME MAXIMUM BENEFIT Lifetime Maximum None None PREVENTIVE SERVICES Well-Child Care (including exams & immunizations) No charge* Deductible, then 40% of Allowed Benefit Adult Physical Examination (including routine GYN visit) No charge* Deductible, then 40% of Allowed Benefit Cancer Screening (prostate, mammogram, pap test, colorectal) No charge* Deductible, then 40% of Allowed Benefit OFFICE VISITS, LABS AND TESTING Office Visits for Illness Deductible, then $20 PCP/$40 Specialist per visit Deductible, then 40% of Allowed Benefit Imaging (MRA/MRS, MRI, PET & CAT scans) Deductible, then $75 per visit (when received at freestanding radiology facility) Deductible, then $100 per visit (when received at outpatient hospital) Deductible, then 40% of Allowed Benefit Lab3 No charge* after deductible Deductible, then 40% of Allowed Benefit X-ray No charge* after deductible Deductible, then 40% of Allowed Benefit Allergy Testing Deductible, then $20 PCP/$40 Specialist per visit Deductible, then 40% of Allowed Benefit Allergy Shots**** Deductible, then $20 PCP/$40 Specialist per visit Deductible, then 40% of Allowed Benefit Physical, Speech and Occupational Therapy4 (limited to 90 days combined/illness/benefit period and combined between in- and out- of-network) Deductible, then $40 per visit Deductible, then 40% of Allowed Benefit Chiropractic Deductible, then $40 per visit Deductible, then 40% of Allowed Benefit Acupuncture Not covered (except when approved or authorized by Plan when used for anesthesia) Not covered (except when approved or authorized by Plan when used for anesthesia) EMERGENCY AND URGENT CARE SERVICES Urgent Care Center $40 per visit $40 per visit^ Emergency Room—Facility Services^^ Deductible, then $250 copay per visit, then 10% of Allowed Benefit (copay waived if admitted) In-network deductible, then $250 copay per visit, then 10% of Allowed Benefit (copay waived if admitted) Emergency Room—Physician Services^^ Deductible, then 10% of Allowed Benefit In-network deductible, then 10% of Allowed Benefit Ambulance Service to a Hospital—for Emergency Services Deductible, then 10% of Allowed Benefit In-network deductible, then 10% of Allowed Benefit