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2022 CareFirst BlueCross BlueShield Advantage DualPrime Plan (HMO-SNP)

The 2022 CareFirst BlueCross BlueShield Advantage DualPrime plan (HMO-SNP) is a Medicare Advantage Prescription Drug Plan for those with both Medicare and Medicaid (Maryland Medical Assistance Program) as a Qualified Medicare Beneficiary (QMB) or a Full Benefit Dual Eligible (FBDE). This plan combines your Medical, Hospital and Prescription Drug coverage with extra services and personalized programs focused on improving your health.

To be eligible for CareFirst BlueCross BlueShield Advantage DualPrime (HMO-SNP), you must also have Medicare Parts A & B and reside in the following Maryland counties: Anne Arundel, Baltimore, Baltimore City, Calvert, Caroline, Carroll, Cecil, Charles, Dorchester, Frederick, Howard, Harford, Kent, Montgomery, Prince Georges, Queen Anne’s, St. Mary’s, Somerset, Talbot, Wicomico and Worcester.

How Much You Pay for Covered Services

Benefits What You Pay with CareFirst BlueCross BlueShield Advantage DualPrime*

Monthly Plan Premium

$0 - $37.00 (Depending on your level of extra help)

Deductible

No Deductible

Maximum Out-of-Pocket (MOOP)

$7,550 annually (This is not a deductible)

Inpatient Hospital Coverage1

  • Days 1-5: $0 per day
  • Days 6-90: $0 per day

Doctor Visits

  • Primary care physician visit: $0 copay
  • Specialist visit: $0 copay

Preventive Care

$0 copay

Emergency Care

$0 copay

Hearing Services

  • Medicare-covered exam: $0 copay
  • Routine hearing exam (1 per year): $0 copay
  • 1 fitting and evaluation with 3 follow up visits within the first year from date of initial fitting: $0 copay
  • Our plan pays up to $1,350 every 3 years for hearing aids
Preventive Dental Services

Preventive Dental Services: $0 copay

  • Oral exam & cleaning: every 6 months
  • Comprehensive oral exam: every 36 months
  • Fluoride treatment: every 6 months
  • Palliative treatment: 3 every 12 months
  • Bitewing x-ray: once every 12 months
  • Panoramic x-ray: once every 36 months
  • Vertical bitewing x-ray: once every 36 months
  • Intraoral imaging: once every 36 months
Comprehensive Dental Services

Comprehensive Dental Services: $0 copay

$1,500 annual allowance towards services (member is responsible for all costs over allowance)

  • Restorative services: 1 per tooth once every 24 months
  • Endodontics: 1 per lifetime, per patient, per tooth
  • Crowns: once per tooth per 60 months
  • Simple extractions
  • Periodontics: 1 per quadrant of scaling every 36 months
  • Periodontal maintenance: once every 3 months
  • Denture repairs: once every 12 months
  • Denture relines/rebase: once every 36 months
  • Denture adjustments: 2 every 12 months
Denture Coverage

Denture Coverage: $0 copay

  • Upper, lower, partial, or any combination
  • Once every 60 months
  • Does not apply to comprehensive dental allowance
Vision Services
  • Medicare-covered exam: $0 copay
  • Medicare-covered eyewear after cataract surgery: $0 copay
  • Routine eye exam: $0 copay—Limited to 1 exam per year
  • $150 annual allowance towards eyewear, includes contact lenses, eyeglass frames and lenses
Transportation $0 copay for 24 one-way trips per year
Part D Deductible No Deductible
Prescription Drug Coverage
  • Generics: $0, $1.35, $3.95 copay (depending on your level of Extra Help)
  • All other drugs: $0, $4.00, $9.85 copay (depending on your level of Extra Help)
Durable Medical Equipment1 $0 copay
Foot Care (Podiatry Services)
  • Medicare Covered Services: $0 copay
  • Routine visit: $0 copay—Limited to 4 visits per year
Meals with Medical Nutrition Therapy1 $0 copay—12 consecutive weeks of meals for members with COPD, CHF, Diabetes, or ESRD. Members will also receive up to 4 medical nutrition therapy sessions. Limited to 4 benefit periods per year.
Readmission Prevention1 $0 copay—14 meals per 1 week period for members post-discharge from an inpatient stay. Limited to 8 benefit periods per year. PERS will also be available to select members upon discharge for a defined period of time.

Personal Emergency Response System (PERS)1

$0 copay—available to select members living with a disability or chronic condition such as COPD, CHF, Diabetes, or ESRD
Over-The-Counter (OTC) Items $150 quarterly allowance through the plan's catalog
Bathroom Safety Devices $0 copay—Limited to 2 devices each year through the plan’s catalog
Health & Wellness Program Members can receive $15 reward cards for completing select preventive screenings and tests

*If your Medicaid status changes from Full Benefit Dual Eligible (FBDE) or Qualified Medicare Beneficiary (QMB), your copays and coinsurances may increase to 20% of the total cost for your medical benefits, the applicable Medicare Part A cost-shares, and 25% of the total cost of your Part D prescription drugs.

1May require prior authorization

2022 Enrollment Form