CareFirst BlueCross BlueShield

BlueChoice HMO HSA Gold $1650 Virtual Connect

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $1,650 Family: $3,300 Per Person: $1,650
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $3,300 Family: $6,600 Per Person: $3,300
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $25 Copay after deductible
Specialist	Standard: $50 Copay after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: $50 Copay after deductible
Non Preferred Brand Drugs	Standard: $70 Copay after deductible
Generic Drugs	Standard: $15 Copay after deductible
Specialty Drugs	Standard: $150 Copay after deductible

Inpatient Coverage

Hospital Services	Standard: $600 Copay per Day after deductible
Inpatient Services	Standard: No Charge after deductible

Emergency and Urgent Care

Emergency Room

Standard: $300 Copay after deductible