CareFirst BlueChoice Advantage

CareFirst BlueChoice Advantage offers you the flexibility and freedom to choose from both in- and out-of-network providers. CareFirst BlueChoice Advantage does not require you to designate a primary care provider (PCP) or to obtain a referral to see a specialist. However, if you select a patient centered medical home (PCMH) PCP, they can help you to better manage your health care needs and overall well-being by providing comprehensive care coordination.

Cost for medical coverage

American University contributes 80% towards individual coverage and 65% for individual +1 and family coverage of the total cost of your medical premium. Your portion of the cost of the medical coverage is deducted from your pay on a pre-tax basis.

Express Scripts drug coverage is included with your cost for the CareFirst medical coverage.

2020 Cost for CareFirst medical coverage

Employee Monthly Cost CareFirst & Express Scripts

Individual under $40K

$37.05

Individual over $40K

$148.21

Individual + 1

$518.27

Family $751.34

This chart provides an overview of the CareFirst BlueChoice Advantage medical plan option. Please refer to medical plan options summary & comparison charts or the plan documents for a more comprehensive listing of medical benefits.

  CareFirst BlueChoice Advantage
  In-network Out-of-network

*The amount that BCBS will pay for a given covered service is determined by the Plan Allowance for that service. The Plan Allowance for covered services is determined by the contracted rate or fee schedule that participating providers have agreed to accept for that service or the rate or fee that is established by law.

Choice of physician

May use any provider in BlueChoice, BluePreferred PPO, or BlueCard PPO.

No referrals required.

Choose any physician. No network limitations.

No referrals required.

Annual deductible

$400 individual

$800 individual +1

$800 family

The in-network annual deductible applies to non-preventive care services. Preventive care such as annual physicals and mammograms are not subject to the deductible, however, copayments still apply.

$1,000 individual

$2,000 individual + 1

$2,000 family

Copayments

$20 primary care

$40 specialty care

No copayment for preventive care office visits.

No copayment for women's preventive health services.

None

Coinsurance

90% paid by health plan*

10% paid by participant

65% paid by health plan*

35% paid by participant

Maximum out-of-pocket expense

$2,750 individual

$5,500 individual +1

$5,500 family

The BlueChoice plan does not cover any portion of your medical bills until you first meet your annual deductible; copayments still apply and do not count toward the deductible.

After the deductible is met for the year, you pay the copayment for certain covered services. Most covered services are reimbursed by BCBS at 90% of plan allowance and you pay 10%. If you reach the maximum out-of-pocket expense for the year, BCBS pays 100% of the plan allowance(s) for covered expenses for the remainder of the year.

$4,000 individual

$8,000 individual +1

$8,000 family

The out-of-network plan does not cover any portion of your medical bills until you first meet your annual deductible.

After the deductible is met for the year, most covered services are reimbursed by BCBS at 65% of plan allowance and you pay 35%. Once you reach the maximum out-of-pocket expense for the year, BCBS pays 100% of the plan allowance(s) for covered expenses for the remainder of the year.

Lifetime maximum

Unlimited

Unlimited

Claim forms

No claim forms to file.

You may need to file your own claims.

If your provider participates with BCBS through another plan, they are required to submit your claims on your behalf and BCBS will reimburse them directly.

Pre-certification

Hospital certifications arranged by physicians.

You are responsible for arranging your own hospital certifications. There is a financial penalty if pre-certification is not arranged.

Please call the provider's office directly to confirm that they still participate in the CareFirst network, even if they are listed as a provider on the CareFirst site.

To find an in-network provider, visit www.carefirst.com and select BlueChoice Advantage as your plan.

If your provider is not listed in the online directory, they are considered out-of-network. You will still have coverage, but your out-of-pocket costs will be greater.

Please call the provider's office directly to confirm that they still participate in the CareFirst network, even if they are listed as a provider on the BCBS site.

To find an in-network provider outside of the DC, Maryland, and Northern Virginia counties of Fairfax, Alexandria, and Arlington, visit www.bcbs.com and enter the first three letters of your member ID number on your insurance card in the "Already a Member" field.

If your provider is not listed in the online directory, they are considered out-of-network. You will still have coverage, but your out-of-pocket costs will be greater.

For behavioral health inpatient pre-certification and emergencies 24 hours/day, 7 days/week, contact Magellan directly at:

Magellan Behavioral Health
(800) 245-7013
Monday through Friday
8 a.m. - 6 p.m.
After hours available for inpatient pre-certification and emergencies 24 hours/day, 7 days/week

When your primary care physician isn’t available and you need urgent care services, CareFirst Video Visit securely connects you with a doctor, day or night, through your smartphone, tablet or computer.

In addition, you can schedule visits for other needs such as behavioral health support from a therapist or psychiatrist, guidance from a certified nutritionist or breastfeeding support from a lactation consultant. It’s a convenient and easy way to get the care you need, wherever you are. Visit www.carefirstvideovisit.com to get started.

Patient centered medical home (PCMH) doctors provide coordination of care for patients with serious and chronic health conditions. If your physician participates, they will get streamlined access to specialist reports, test results, and hospitalization information. A nurse in your physician's office is designated to be available to answer questions, support the treatment process, and be proactive in providing care.

The program is confidential, voluntary, and provided at no additional cost to you. If you are contacted by your doctor, we strongly encourage you to enroll in the program so that you can get personalized care and support for you and your family.

To find out if your physician participates in the program, go to www.carefirst.com and look for the PCMH symbol near the provider's name.

CareEssentials is a personalized, confidential, and voluntary health coaching program to help people with chronic conditions, like diabetes or asthma, to manage their overall health. Highly trained nurses provide one-on-one telephone support and health information, help you prepare questions for doctor visits, answer questions about new diagnoses and medications; and assist with other health issues.

The CareEssentials team is available to support your relationship with your physician, not replace it. They will provide coordination of care with your physician. The program is administered by Healthways, Inc., a leading provider of integrated health management.

Expectant mothers can take advantage of the CareFirst Great Beginnings pregnancy support program designed to supplement the prenatal care and education you receive from your doctor, at no additional cost to you.

When you enroll in Great Beginnings, a nurse case manager will review your medical history. If you experience complications during your pregnancy, they will work closely with your doctor to coordinate necessary services.

You are covered while traveling outside the U.S. Visit the BlueCross BlueShield Global Core Website for more information.

  • Enter "RMR" in the sections that says, "Enter the first three letters of the Member ID on your card."

Some restrictions apply. Not all countries are covered.

A self-insured plan means that the university pays the claims. CareFirst administers the claims from health providers for AU faculty and staff. The university does not receive any private medical information or any details about claims incurred.

Our premiums for CareFirst are based on our claims experience. If we have a lot of claims in a year, the university has to pay more. And that means the next year the premiums go up.

But you can help. When you choose generic medications, stick with a healthy regimen, and get preventive screenings, you generally incur less in claims. The lower our claims, the lower our premiums are in the next year.

American University makes every effort to ensure the accuracy of the information that appears on the benefits site. However, if there are discrepancies between the information presented and the legal documents governing a plan or program (the "plan documents"), the plan documents will always govern. American University reserves the right to amend or terminate any benefit plan at its sole discretion at any time, for any reason.

COVID-19 Medical Plan Waivers

CareFirst is waiving expenses related to the diagnosis and treatment of COVID-19.

COVID-19 Waivers

Terms to know

In-network means you have lower out-of-pocket costs when you choose a BlueChoice, BluePreferred PPO, or BlueCard PPO network provider. If you are out of the DC, Maryland, and Northern Virginia, you may choose any provider nationwide that participates with a BlueCard PPO plan and receive in-network benefits.

Out-of-network provides a lower level of coverage in exchange for the freedom to seek care from any provider you choose. If you receive services from a provider outside of the BlueChoice, BluePreferred PPO, or BlueCard PPO networks, you will have to: 1) pay the provider's actual charge at the time you receive care, 2) file a claim for reimbursement, and 3) satisfy a deductible and coinsurance.