Review the Cost Information Shown Below and Consult the Msds

The information contained in this comparison tool is not the official statement of benefits. Before making your final enrollment decision, e'er refer to the private FEHB brochure which is the official statement of benefits. The amounts shown beneath indicate what yous will pay for each class of service. When you meet a plus sign (+), it means y'all must pay the stated coinsurance AND any difference between your Plan'due south allowance and the provider'south billed amount. When a "yes" appears indicating that there is coverage for a specific service, you must bank check the plan brochure for your cost share. Note: HDHP plans require that the combined medical and pharmacy deductible be met before traditional coverage begins. traditional coverage begins.

Costs & Network

Disclaimer: In some cases, the enrollee share of premiums for the Self Plus One enrollment type will be college than for the Self and Family enrollment blazon. Enrollees who wish to cover ane eligible family unit member are free to elect either the Self and Family or Self Plus Ane enrollment type. Bank check premiums on our website at world wide web.opm.gov/fehbpremiums.

Self

Cocky Plus Ane

Self & Family

Programme Selection Comparison Tool

Plans	Blue Cross and Blue Shield Service Do good Plan (Basic)
Program Links	[Website] Brochure Link [Summary of Benefits] [Provider Directory] [RX Pricing Tool]
General Information - State	Maryland
General Information - Enrollment Code - Self	111
Full general Information - Enrollment Code - Self & Family	112
Full general Information - Enrollment Code - Self Plus 1	113
General Information - Carrier Code	11
General Information - Telephone Number	i-800-411-2583
Biweekly Premium	$ 80.18
Biweekly Premium	$ 196.13
Biweekly Premium	$ 212.29

Plans - Networks	Bluish Cross and Bluish Shield Service Benefit Plan (Basic) - In-Network i
Annual Deductible Annual Deductible: The corporeality you may accept to pay for covered wellness care services earlier the program begins to pay. Some plans have both an overall deductible for all or most covered items/services, simply some also have separate deductibles for specific types of services (east.g. prescription services).	None
Annual Deductible Annual Deductible: The amount y'all may have to pay for covered wellness care services before the plan begins to pay. Some plans have both an overall deductible for all or well-nigh covered items/services, only some too accept split deductibles for specific types of services (eastward.g. prescription services).	None
Annual Deductible Annual Deductible: The amount you may accept to pay for covered health care services before the plan begins to pay. Some plans accept both an overall deductible for all or most covered items/services, but some also have separate deductibles for specific types of services (e.chiliad. prescription services).	None
Type of Account	None
Medical Account Contribution The amount of funds bachelor to yous for paying your out-of-pocket qualified medical expenses through a premium pass-through contribution or a virtual business relationship.	N/A
Medical Account Contribution The amount of funds bachelor to you for paying your out-of-pocket qualified medical expenses through a premium pass-through contribution or a virtual account.	North/A
Medical Account Contribution The amount of funds bachelor to you lot for paying your out-of-pocket qualified medical expenses through a premium pass-through contribution or a virtual account.	N/A
Internet Deductible A net deductible is the sum of your deductible minus whatsoever medical account fund.	None
Net Deductible A net deductible is the sum of your deductible minus any medical account fund.	None
Internet Deductible A net deductible is the sum of your deductible minus any medical business relationship fund.	None
Annual Out-of-Pocket Maximum Annual Maximum Out of Pocket: Yearly amount the Federal government sets as the near each individual or family is required to pay in cost sharing (e.g. copayments, deductibles and coinsurance) during the plan year for covered, in-network services. This amount may be higher than the out of pocket limits the program sets.	$6,500.00
Annual Out-of-Pocket Maximum Annual Maximum Out of Pocket: Yearly amount the Federal government sets every bit the well-nigh each individual or family unit is required to pay in cost sharing (e.m. copayments, deductibles and coinsurance) during the plan yr for covered, in-network services. This corporeality may be higher than the out of pocket limits the plan sets.	$13,000.00
Annual Out-of-Pocket Maximum Annual Maximum Out of Pocket: Yearly amount the Federal government sets as the most each private or family is required to pay in cost sharing (e.g. copayments, deductibles and coinsurance) during the plan year for covered, in-network services. This amount may exist higher than the out of pocket limits the plan sets.	$13,000.00
Member Price with Medicare A & B Principal - Deductible Waiver Member Cost with Medicare A & B Primary - This field volition point either the corporeality of your annual deductible or that the deductible has been waived (forgiven) when Medicare A and B is the primary coverage.	Northward/A
Member Cost with Medicare A & B Primary - Out-of-Pocket Maximum Member Toll with Medicare A & B Master - This is the most you have to pay annually in toll-sharing (deductibles, copayments and coinsurance) for covered, in-network services in your FEHB plan when Medicare A and B is your main coverage.	$6500 $13000
Member Price with Medicare A & B Primary - Primary Care Role Visit with Medicare A & B Primary Fellow member Toll with Medicare A & B Primary - This is the amount you lot pay for a primary care visit. When you have Medicare A and B, some plans will waive the copay.	Member Pays Zero
Member Cost with Medicare A & B Primary - Specialty Office Visit Member Cost with Medicare A & B Primary - This is the corporeality you pay for a Specialty care visit. When you accept Medicare A and B, some plans will waive the copay.	Fellow member Pays Zero
Member Cost with Medicare A & B Main - Inpatient Infirmary Member Price with Medicare A & B Primary - This is the amount you pay for an inpatient infirmary stay. When you accept Medicare A and B, some plans waive this amount.	Member Pays Nothing
Fellow member Toll with Medicare A & B Primary - Outpatient Hospital Member Cost with Medicare A & B Main - This is the corporeality you lot pay for an outpatient hospital visit when you have Medicare Parts A & B every bit your primary coverage.What is the amount a member with Medicare A and B pays for an outpatient hospital visit?	Member Pays Nothing
Member Toll with Medicare A & B Master - Office B Premium Reimbursement Member Cost with Medicare A & B Primary - If a plan reimburses you for your Part B premiums, this displays the maximum amount that you will be reimbursed. A 'No" means that the premium will not exist reimbursed.	$800 Max
Main/Specialty Care - Preventive Intendance Primary/Specialty Care - What is the member cost share for Preventive Care, as defined by the U.Southward. Preventive Services Chore Force with a rating of A or B?	Fellow member Pays Nothing
Primary/Specialty Intendance - Primary Care Function Visit Primary/Specialty Care - The amount you pay for a visit to a master care practitioner (typically an One thousand.D. or D.O., but can include other licensed providers).	$xxx
Chief/Specialty Care - Specialist Role Visit Principal/Specialty Care - The amount you lot pay for a visit to a provider focusing on a specific area of medicine. Some plans require a referral from your main care provider for you to see a specialist. You must go a referral, if required, or your plan may not pay for the services.	$40
Master/Specialty Care - Plan Requires Referral to See Certain Specialists Primary/Specialty Care - A written order from your main care provider for you to come across a specialist or get certain health care services. Some plans may crave you need to get a referral before yous can get health intendance services from anyone other than your primary intendance provider. In those plans, if y'all don't get a referral first, the programme may non pay for the services	No
Emergency & Urgent Care - Emergency Care Emergency & Urgent Intendance - What is the member cost share for Emergency Care?	$175
Emergency & Urgent Care - Urgent Intendance Emergency & Urgent Care - What is the member cost share for Urgent Care?	$35
Emergency & Urgent Care - Out-of-Pocket Waived Emergency & Urgent Care - Is a fellow member'due south Out-of-Pocket toll waived when the fellow member is admitted to the hospital post-obit ER treatment? Select "NA" if a fellow member pays cipher for whatsoever medical emergency.	Yep
Surgery & Hospital Charges - Doctor Costs Inpatient Surgery Surgery & Hospital Charges - The amount you will pay for a physician to perform inpatient surgery.	$200
Surgery & Hospital Charges - Infirmary Inpatient Toll Per Access Surgery & Hospital Charges - This is the amount yous pay earlier the Plan pays benefits when yous are admitted every bit an inpatient to a hospital.	$175 Per Day Up To $875 Per Admission
Surgery & Infirmary Charges - Room & Board Charges Surgery & Hospital Charges - This is the amount you pay for covered Room & Lath charges while an inpatient in a infirmary.	Member Pays Nothing
Surgery & Hospital Charges - Other Inpatient Costs Surgery & Hospital Charges - This is the amount you pay for other costs associated with inpatient surgery.	Member Pays Nothing
Surgery & Hospital Charges - Doctor Costs Outpatient Surgery Surgery & Hospital Charges - This is the amount you pay for a doctor to perform surgery in an outpatient hospital setting or ambulatory surgery centre.	$150 Or $200
Surgery & Hospital Charges - Other Outpatient Costs Surgery & Hospital Charges - This is the amount you lot pay for other outpatient care at a hospital (not surgery or emergency room services).	$100 Per Day Or $150 Per Day
Lab, 10-Ray & Other Diagnostic Tests - Unproblematic Diagnostic Tests/Procedures Lab, X-Ray & Other Diagnostic Tests - What is the fellow member cost share for Elementary Diagnostic Tests/Procedures (e.1000., blood tests, urinalysis, ultrasounds)?	$0 Or $thirty Or $40
Lab, X-Ray & Other Diagnostic Tests - Complex Diagnostic Tests/Procedures Lab, X-Ray & Other Diagnostic Tests - What is the member cost share for Circuitous Diagnostic Tests/Procedures (east.one thousand., CT scans, MRIs, PET scans, sleep labs)?	$40 Or $100
Lab, Ten-Ray & Other Diagnostic Tests - Enhanced Lab Network Lab, X-Ray & Other Diagnostic Tests - What is the member toll share for Enhanced lab Network?	N/A
Prescription Drugs - Dissever Annual Out-of-Pocket Maximum	None
Prescription Drugs - Separate Annual Deductible	None
Prescription Drugs - Separate Annual Deductible	None
Prescription Drugs - Split up Annual Deductible	None
Prescription Drugs - Retail Generic Prescription Drugs - The amount you will pay to fill a prescription for retail generic drugs.	Tier one: $x
Prescription Drugs - Retail Brand Prescription Drugs - The amount you volition pay to fill a prescription for retail brand name drugs.	Tier two: $55 Tier 3: sixty% $75 min
Prescription Drugs - Specialty Prescription Drugs - Your cost share for specialty prescription drugs. Specialty prescription drugs are high cost, circuitous drugs placed on a specialty tier of the formulary and/or dispensed from a designated specialty pharmacy.	Tier 4: $85 Or Tier iv: $80 Tier five: $110 Or Tier 5: $100
Prescription Drugs - Mail Service Pharmacy Do good Prescription Drugs - This is the amount you pay for a postal service guild prescription. These are medications sent via mail for maintenance prescriptions, typically greater than a xxx-day supply.	No
Prescription Drugs - Postal service Order Chemist's Restriction Prescription Drugs - Mail order drug dispensing may exist restricted to a specific mail order pharmacy. For more details, refer to the medication pricing tool.	N/A
Prescription Drugs - Specialty Pharmacy Restriction Prescription Drugs - Specialty drug dispensing may be restricted to a specific specialty pharmacy. For more than details, refer to the medication pricing tool.	Yes
Handling Therapies - Applied Behavioral Analysis (ABA) Handling Therapies - This is the amount you pay for Applied Behavior Analysis (ABA) coverage.	$30 Or $40
Treatment Therapies - Chiropractic Handling Therapies - Your toll share for chiropractic care.	$thirty
Treatment Therapies - Occupational Therapy Treatment Therapies - Your price share for occupational therapy.	$30 Or $40
Treatment Therapies - Physical Therapy Treatment Therapies - Your cost share for physical therapy.	$thirty Or $twoscore
Treatment Therapies - Spoken language Therapy Treatment Therapies - Your cost share for speech therapy.	$30 Or $forty
Dental - Preventive Dental for Adults Dental - Does the programme comprehend Preventive Dental for Adults?	Yep
Dental - Preventive for Children Dental - Does the plan encompass Preventive Dental for Children?	Yeah
Dental - Minor Restorative for Adults Dental - Does the plan embrace Pocket-size Restorative for Adults (due east.g., fillings, local anesthesia)?	No
Dental - Minor Restorative for Children Dental - Does the program embrace Minor Restorative for Children (due east.k., fillings, local anesthesia)?	No
Dental - Major Restorative for Adults Dental - Does the plan embrace Major Restorative for Adults (east.g., endodontics, crowns, prosthodontics)?	No
Dental - Major Restorative for Children Dental - Does the programme cover Major Restorative for Children (e.one thousand., endodontics, crowns, prosthodontics)?	No
Dental - Orthodontic Dental - Does the plan comprehend Orthodontics?	No
Vision - Routine Center Exams Vision - Does the plan cover Routine Eye Exams?	No
Vision - Eye Exams for Medical Condition or Non-Surgical Handling Vision - Does the program cover Eye Exams for Medical Status or Non-Surgical Handling?	Yes
Vision - Eyeglass Frames & Lenses Vision - Does the plan embrace Eyeglass Frames and Lenses?	No
Vision - Contacts Vision - Does the plan cover Contacts?	No
Alternative Care - Alternative Intendance Alternative Care - Your plan may cover some type of alternative care such equally: acupuncture, massage therapy, hypnotherapy, holistic medicine, Yoga, herbal treatments, or naturopathic services. Delight consult the program brochure for more than data.	Yeah

Key: Excellent Very Good Practiced Fair Poor NA (NA is displayed if a plan did non report or is unable to report a consequence in this coverage area.)

Plans	Blue Cross and Blue Shield Service Do good Program (Bones)
Quality - Decision-making High Blood Pressure People with high blood pressure level receive effective treatment.
Quality - Comprehensive Diabetes Care - HbA1c <8% Do people with diabetes accept their condition under control?
Quality - Timeliness of Prenatal Intendance Pregnant women receive intendance in the starting time trimester.
Quality - Avoidance of Antibody Treatment for Acute Bronchitis / Bronchiolitis - Ages eighteen-64 Appropriate use of antibiotics for acute bronchitis.
Quality - Asthma Medication Ratio Appropriate ratio of controller medications to total asthma medications.
Quality - Chest Cancer Screening Do women who need screening mammograms become them?
Quality - Follow-Up Later Emergency Section Visit for Booze and Other Drug Abuse or Dependence - 30-day Follow-upward appointment inside xxx days of discharge.
Quality - Follow-Up Afterward Emergency Department Visit for Mental Illness - 30-day Follow-upwardly date within 30 days of discharge.
Quality - Well-Child Visits in First xxx Months of Life (First 15 Months) Recommended well-child visits completed.
Quality - Apply of Imaging Studies for Depression Back Hurting Appropriate handling of lower back hurting.
CustomerService - Overall Plan Satisfaction How pleased are customers with the plan overall?
CustomerService - Claims Processing How quickly practice customers say the plan handles claims?
CustomerService - Getting Needed Care Members report getting the care they need.
CustomerService - Coordination of Care Members say that their doctors know about care from other providers.

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Source: https://www.opm.gov/healthcare-insurance/healthcare/plan-information/compare-plans/fehb/PlanDetails?FFSSearch=on&Medicare=False&ZipCode=20772&IncludeNationwide=True&empType=a&payPeriod=c&plans=111MD&AnnualDeductible=&AnnualOutofPocketMaximum=&PassThrough=&Premiums=&MedicalAccount%5BIncludeNo%5D=true&MedicalAccount%5BIncludeYes%5D=true&MedicalAccount%5BIncludeNone%5D=true&PrimaryCareOfficeVisit%5BCopayment%5D=30&PrimaryCareOfficeVisit%5BCoinsurance%5D=30&SpecialistOfficeVisit%5BCopayment%5D=60&SpecialistOfficeVisit%5BCoinsurance%5D=30&DoctorCostInpatientSurgery%5BCopayment%5D=250&DoctorCostInpatientSurgery%5BCoinsurance%5D=30&DoctorCostInpatientSurgery%5BIncludeNone%5D=true&RetailGeneric%5BCopayment%5D=85&RetailGeneric%5BCoinsurance%5D=50&RetailGeneric%5BIncludeNone%5D=true&RetailBrand%5BCopayment%5D=85&RetailBrand%5BCoinsurance%5D=60

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