CareFirst PPO Plan In-Network Coverage | CareFirst HRA Plan In-Network Coverage | ||
---|---|---|---|
Annual Deductible | |||
You | $1,000 | $1,750 | |
You + Spouse/Partner | $2,000 | $3,500 | |
You + Child(ren) | $2,000 | $4,175 | |
Family | $2,000 | $4,500 | |
Money from Sodexo (only for HRA plan) | |||
You | No plan account | $750 | |
You + Spouse/Partner | No plan account | $1,175 | |
You + Child(ren) | No plan account | $1,175 | |
Family | No plan account | $1,500 | |
Copays and Coinsurance | |||
Preventive Care | $0 (no deductible) | $0 (no deductible) | |
Primary Care Office Visit | $30 copay | 20% after deductible | |
Specialist Office Visit | $40 copay | 20% after deductible | |
Physical, Speech and Occupational Therapy Visits | $15 copay | $15 copay | |
Video Visit | $0 Urgent care, cost varies for other services | $0 Urgent care, cost varies for other services | |
Urgent Care | $30 copay | 20% after deductible | |
Emergency Room | $150 copay (waived if admitted) then 30% after deductible | 20% after deductible | |
Hospital Coverage | $250 copay, then 30% after deductible | 20% after deductible | |
Most Other Services | 30% after deductible | 20% after deductible | |
Out-of-Pocket Maximum | |||
Individual | $5,000 | $6,350 | |
Family | $12,700 | $12,700 |