Active-Medical Plans

City of Baltimore
Medical Plan Comparison Chart - Active Members
Benefits in Effect 01–01-07

BENEFITS SUMMARY	UnitedHealthcare POINT-OF-SERVICE 1-877-462-5027 www.myuhc.com IN–PLAN OUT–OF–PLAN			KAISER PERMANENTE HMO 1–800–777–7902 www.kaiserpermanente.org	OPTIMUM CHOICE HMO 1–800–331–2102 www.mamsiUnited Healthcare.com	CAREFIRST BLUE CROSS BLUE SHIELD PREFERRED PROVIDER PLAN 1–800–535–2292 www.carefirst.com PREFERRED NON–PREFERRED		CAREFIRST BLUE CROSS BLUE SHIELD TRADITIONAL 1–800–535–2292 www.carefirst.com
ARE Referrals Required In This Plan?	no	no		referrals from Primary Care Physician are required; phone or fax referrals may be permitted; extended referrals for certain conditions (reviewed every 6 months)	referrals from Primary Care Physician are required except: standing referrals for certain conditions; no referral needed for OB/GYN and eye refraction	no	no	no
Dependent Eligibility	unmarried dependent children until the end of the calendar year they reach age 19; full-time students to the end of the calendar year they reach age 25 or cease to be a full-time student, whichever occurs first	unmarried dependent children until the end of the calendar year they reach age 19; full-time students to the end of the calendar year they reach age 25 or cease to be a full-time student, whichever occurs first		unmarried dependent children until the end of the calendar year they reach age 25 regardless of student status	unmarried dependent children until the end of the calendar year they reach age 19; full-time students to the end of the calendar year they reach age 25 or cease to be a full-time student, whichever occurs first	unmarried dependent children until the end of the calendar year they reach age 19; full-time students to the end of the calendar year they reach age 23 or cease to be a full-time student, whichever occurs first	unmarried dependent children until the end of the calendar year they reach age 19; full-time students to the end of the calendar year they reach age 23 or cease to be a full-time student, whichever occurs first	unmarried dependent children to the end of the calendar year they reach age 19
COMMON AND PREVENTIVE SERVICES
Physician’s Office Visits	$5 copay per visit	$5 copay per visit 100% allowed benefit**	$5 copay per visit waived for children up to age 5		$5 copay per visit	$10 copay per visit 100% allowed benefit	80% allowed benefit		major medical subject to deductible and coinsurance if applicable
Specialist Office Visits	$5 copay per visit	$5 copay per visit 100% allowed benefit**	$5 copay per visit waived for children up to age 5		$5 copay per visit	$15 copay per visit 100% allowed benefit	80% allowed benefit		major medical subject to deductible and coinsurance if applicable
Routine GYN Examinations (one per year)	$5 copay per visit	$5 copay per visit 100% allowed benefit**	$5 copay per visit		$5 copay per visit; referral is not needed from Primary Care Physician	$15 copay per visit 100% allowed benefit	80% allowed benefit		no benefit
Hearing Exams	$5 copay per visit (screening only, children through 17 years of age)	$5 copay per visit 100% allowed benefit** (screening only, children through 17 years of age)	$5 copay		$5 copay for hearing exam	100% allowed benefit with medical diagnosis; one exam every 36 months (routine exams excluded)	80% allowed benefit with medical diagnosis; one exam every 36 months (routine exams excluded)		no benefit

BENEFITS SUMMARY	UnitedHealthcare POINT-OF-SERVICE 1-877-462-5027 www.myuhc.com IN–PLAN OUT–OF–PLAN		KAISER PERMANENTE HMO 1–800–777–7902 www.kaiserpermanente.org	OPTIMUM CHOICE HMO 1–800–331–2102 www.mamsiUnited Healthcare.com	CAREFIRST BLUE CROSS BLUE SHIELD PREFERRED PROVIDER PLAN 1–800–535–2292 www.carefirst.com PREFERRED NON–PREFERRED		CAREFIRST BLUE CROSS BLUE SHIELD TRADITIONAL 1–800–535–2292 www.carefirst.com
COMMON AND PREVENTIVE SERVICES Continued
Immunizations	covered in full	100% allowed benefit**	covered in full up to age 5 Hepatitis B vaccination covered in full $5 copay	covered in full when done in conjunction with an office visit Hepatitis B vaccination covered in full to age 18	100% allowed benefit included in well baby visits Hepatitis B vaccination covered in full	80% allowed benefit included in well baby visits Hepatitis B vaccination covered in full	no benefit
Mammography	covered in full	100% allowed benefit**	covered in full	covered in full	100% allowed benefit; one baseline between ages 35 – 39; women ages 40 – 49, one every other year; women 50 and above every calendar year in approved ACR Facility	80% allowed benefit; one baseline between ages 35 – 39; women ages 40 – 49, one every other year; women 50 and above every calendar year in approved ACR Facility	100% allowed benefit; one baseline between ages 35 – 39; women ages 40 – 49, one every other year; women 50 and above every calendar year in approved ACR Facility
Routine Physical	$5 copay per visit	$5 copay per visit 100% allowed benefit**	$5 copay per visit	$5 copay per visit	$10 copay per visit; 100% allowed benefit (includes all related services, one every 36 months)	80% allowed benefit including all related services, one every 36 months	no benefit
Well Baby Care	$5 copay per visit	$5 copay per visit 100% allowed benefit**	covered in full to age 5	$5 copay per visit	100% of allowed benefit after $10 copay per visit; limit of: 4 visits 0 – 11 months; 3 visits 12 – 23 months; 1 annual visit 2 – 6 years; 1 annual visit 7 – 12 years, with $75 maximum payment	80% allowed benefit; limit of: 4 visits 0 – 11 months; 3 visits 12 – 23 months; 1 annual visit 2 – 6 years; 1 annual visit 7 – 12 years, with $75 maximum payment	no benefit
EMERGENCY TREATMENT
Ambulance Service	covered in full, if emergency only	100% allowed benefit**, if emergency only	covered in full when medically necessary	covered in full when medically necessary	major medical subject to deductible and coinsurance if applicable	major medical subject to deductible and coinsurance if applicable	major medical subject to deductible and coinsurance if applicable

Text Box: *If you elect coverage through either the CareFirst Blue Cross Blue Shield Traditional or PPN plan, your Mental Health and Substance Abuse benefits will be provided through ValueOptions. They may be reached at (866) 468–5633.
** Allowed benefit is the 50th percentile of R & C .
*** If you go to a doctor or facility out of the network, you may be “balance billed.”

BENEFITS SUMMARY	UnitedHealthcare POINT-OF-SERVICE 1-877-462-5027 www.myuhc.com IN–PLAN OUT–OF–PLAN		KAISER PERMANENTE HMO 1–800–777–7902 www.kaiserpermanente.org	OPTIMUM CHOICE HMO 1–800–331–2102 www.mamsiUnited Healthcare.com	CAREFIRST BLUE CROSS BLUE SHIELD PREFERRED PROVIDER PLAN 1–800–535–2292 www.carefirst.com PREFERRED NON–PREFERRED		CAREFIRST BLUE CROSS BLUE SHIELD TRADITIONAL 1–800–535–2292 www.carefirst.com
EMERGENCY TREATMENT Continued
Emergency Room	$25 copay (waived if admitted)	$25 copay (waived if admitted)	$25 copay (waived if admitted); out of area additional benefit up to $500 per member per year for follow-up services for members temporarily out of service area and approved as emergency situation	$25 copay (waived if admitted)	$25 copay (waived if admitted); hospital emergency room charges only	$25 copay (waived if admitted); hospital emergency room charges only	100% allowed benefit
HOSPITAL — INPATIENT SERVICES
Anesthesia	covered in full	100% allowed benefit**	covered in full	covered in full	100% allowed benefit	80% allowed benefit	100% allowed benefit
Hospital Services, Room, Board & General Nursing Services	covered in full	100% allowed benefit**	covered in full	covered in full	(ACUTE INPATIENT REHABILITATION NOT COVERED) 100% allowed benefit 365 inpatient days	(ACUTE INPATIENT REHABILITATION NOT COVERED) $100 deductible per admission, then plan pays 80% up to $1,500 out of pocket maximum per admission then 100% allowed benefit 365 inpatient days	(ACUTE INPATIENT REHABILITATION NOT COVERED) $50 deductible per person for first admission in calendar year then covered at 100% allowed benefit 365 inpatient days
Diagnostic Lab Work & X–rays	covered in full	100% allowed benefit**	covered in full	covered in full	100% allowed benefit 365 inpatient days	80% allowed benefit 365 inpatient days	100% allowed benefit 365 inpatient days
Medical/Surgical Physician Services, Physical & Rehabilitation Therapy	covered in full	100% allowed benefit**	covered in full	covered in full	100% allowed benefit 365 inpatient days	80% allowed benefit 365 inpatient days	100% allowed benefit 365 inpatient days
Organ Transplant	covered in full for non-experimental transplants; pre- authorization required	100% allowed benefit**, for non-experimental transplants limited to $30,000 per transplant; pre-authorization required	covered in full for heart, heart–lung, liver, kidney, lung, non-experimental bone marrow, cornea simultaneous pancreas/kidney	covered in full for non-experimental kidney, bone marrow, cornea transplants; liver, heart, heart–lung, or pancreas pre-authorization required	kidney, bone marrow, cornea transplants 100% allowed benefit; liver, heart, heart–lung, or pancreas pre-authorization required with a maximum of $1 million per transplant	kidney, bone marrow, cornea transplants 100% allowed benefit; liver, heart, heart–lung, or pancreas pre- authorization required with a maximum of $1 million per transplant	kidney, bone marrow, cornea transplants 100% allowed benefit; liver, heart, heart–lung, or pancreas pre-authorization required with a maximum of $1 million per transplant

Text Box: *If you elect coverage through either the CareFirst Blue Cross Blue Shield Traditional or PPN plan, your Mental Health and Substance Abuse benefits will be provided through ValueOptions. They may be reached at (866) 468–5633.

** Allowed benefit is the 50th percentile of R & C.
*** If you go to a doctor or facility out of the network, you may be “balance billed.”

BENEFITS SUMMARY	UnitedHealthcare POINT-OF-SERVICE 1-877-462-5027 www.myuhc.com IN–PLAN OUT–OF–PLAN		KAISER PERMANENTE HMO 1–800–777–7902 www.kaiserpermanente.org	OPTIMUM CHOICE HMO 1–800–331–2102 www.mamsiUnited Healthcare.com	CAREFIRST BLUE CROSS BLUE SHIELD PREFERRED PROVIDER PLAN 1–800–535–2292 www.carefirst.com PREFERRED NON–PREFERRED		CAREFIRST BLUE CROSS BLUE SHIELD TRADITIONAL 1–800–535–2292 www.carefirst.com
HOSPITAL — OUTPATIENT SERVICES
Chemotherapy	$5 copay per visit	$5 copay per visit**, 100% allowed benefit	$5 copay per visit	$5 copay per visit	100% allowed benefit	80% allowed benefit	100% allowed benefit
Diagnostic Lab Work & X–rays	covered in full	100% allowed benefit**	covered in full	covered in full	100% allowed benefit	80% allowed benefit	100% allowed benefit
Outpatient Surgery	covered in full	100% allowed benefit**	$5 copay per visit	covered in full	100% allowed benefit	80% allowed benefit	100% allowed benefit
Physical & Rehabilitation Therapy	$5 copay per visit; combined maximum 60 visits per year for short term care preauthorization required	$5 copay per visit, 100% allowed benefit**; combined maximum 60 visits per year for short term care preauthorization required	$5 copay per visit up to 30 visits per injury	$5 copay per visit combined maximum of 90 days or 90 visits per illness or injury	$10 copay per visit 100% allowed benefit 100 visits per calendar year for physical, speech, and occupational therapies combined. pre-certification required after first 10 visits	80% allowed benefit for 100 visits per calendar year for physical, speech, and occupational therapies combined. pre-certification required after first 10 visits	major medical benefit 100 visits per year, physical, speech, and occupational therapies combined subject to deductible and coinsurance if applicable. pre-certification required after first 10 visits
Pre–admission Testing	$5 copay per visit, testing covered in full	$5 copay per visit 100% allowed benefit**	$5 copay per visit	covered in full	100% allowed benefit	80% allowed benefit	100% allowed benefit
Radiation Therapy	$5 copay per visit	$5 copay per visit, 100% allowed benefit**	$5 copay per visit	$5 copay per visit	100% allowed benefit	80% allowed benefit	100% allowed benefit
MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS — INPATIENT
Alcohol and Substance Abuse Care	covered in full preauthorization required	100% allowed benefit** preauthorization required	covered in full	covered in full	(provided through ValueOptions)* 100% 7 days detox. per calendar year. 100% up to 30 days in approved facility. pre-certification required	(provided through ValueOptions)* 7 days detox. at 80% after $100 deductible – 30 days in approved facility at 80%	(provided through ValueOptions)* 100% 7 days detox. per calendar year. 100% up to 30 days in approved facility. pre-certification required
Mental Health Benefits	covered in full preauthorization required	100% allowed benefit** preauthorization required	covered in full	covered in full	(provided through ValueOptions)* 30 days in a 180 day period covered in full – 90 day renewal. pre-certification required	(provided through ValueOptions)* $100 deductible per admission; 30 days per 180 day period, paid at 80% – 90 day renewal. pre-certification required	(provided through ValueOptions)* up to 30 days in a 180 day period covered in full – 90 day renewal. pre-certification required

Text Box: *If you elect coverage through either the CareFirst Blue Cross Blue Shield Traditional or PPN plan, your Mental Health and Substance Abuse benefits will be provided through ValueOptions. They may be reached at (866) 468–5633.

** Allowed benefit is the 50th percentile of R & C.
*** If you go to a doctor or facility out of the network, you may be “balance billed.”

BENEFITS

SUMMARY

UnitedHealthcare

POINT-OF-SERVICE
1-877-462-5027
www.myuhc.com

IN–PLAN OUT–OF–PLAN

KAISER PERMANENTE

HMO
1–800–777–7902
www.kaiserpermanente.org

OPTIMUM CHOICE

HMO
1–800–331–2102
www.mamsiUnited
Healthcare.com

CAREFIRST BLUE CROSS BLUE SHIELD PREFERRED PROVIDER PLAN

1–800–535–2292
www.carefirst.com

PREFERRED NON–PREFERRED

CAREFIRST
BLUE CROSS
BLUE SHIELD TRADITIONAL

1–800–535–2292
www.carefirst.com

MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS — OUTPATIENT

Alcohol and Substance Abuse Care

1 – 5 visits
20% copay;

6 – 30 visits
35% copay;

31 and above 50%

preauthorization required

1 – 5 visits
20% copay; allowed benefit**

6 – 30 visits
35% copay; allowed benefit**

31 and above 50%; allowed benefit**

preauthorization required

$20 copay for individual;

$10 copay for group; unlimited visits

1 – 5 visits
20% copay;

6 – 30 visits
35% copay;

31 and above 50% copay

(provided through ValueOptions)*

100% up to 30 visits per calendar year or $3,000 maximum per year. pre-certification required after 8th visit

(provided through ValueOptions)*

$25 copay per visit up to 30 visits per year or $3,000 maximum per year. pre-certification required after 8th visit

(provided through ValueOptions)*

100% up to 30 visits per calendar year or $3,000 maximum per year. pre-certification required after 8th visit

Mental Health Benefits

1 – 5 visits
20% copay;

6 – 30 visits
35% copay;

31 and above 50%

preauthorization required

1 – 5 visits
20% copay; allowed bene