CareFirst BlueCross BlueShield

BlueChoice HMO Standard Gold $500

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Plan Overview

Medical Deductible	Individual: $500 Family: $1,000 Per Person: $500
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $4,950 Family: $9,900 Per Person: $4,950

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to a 30 day supply of Prescription Drugs.
Non Preferred Brand Drugs	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to a 30 day supply of Prescription Drugs.
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to a 30 day supply of Prescription Drugs.
Specialty Drugs	CoPay: $150.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to a 30 day supply of Prescription Drugs.

Inpatient Coverage

Hospital Services	CoPay: $600.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Prior authorization is required except for emergency admissions and all maternity admissions. Hospitalization solely for rehabilitation limited to ninety (90) days per Benefit Period. Limitations for other reasons are variable and outlined in respective section.
Inpatient Services	CoPay: No Charge after deductible CoInsurance: No Charge after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $300.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $600.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: No Charge Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Benefit Period

Major Dental Care

Routine Dental Checkups for Children	CoPay: No Charge CoInsurance: No Charge Covered: Covered Limit Quantity: 2 Limit Unit : Procedure(s) per Benefit Period
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered

Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc. and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.

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