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CareFirst BlueCross BlueShield

BlueChoice HMO Standard Silver $4,000

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    Plan Overview

    Medical Deductable
    • Individual: $4,000
    • Family: $8,000
    • Per Person: $4,000
    Prescription Drug Deductible
    • Individual: $250
    • Family: not applicable
    • Per Person: $250
    Combined Medical and Drug Out of Pocket Maximum
    • Individual: $8,250
    • Family: $16,500
    • Per Person: $8,250

    Office Visit

    Primary Doctor
    • CoPay: $40.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    Specialist
    • CoPay: $80.00
    • CoInsurance: Not Applicable
    • Covered: Covered

    Prescription Drug Information

    Preferred Brand Drugs
    • CoPay: $50.00 Copay after deductible
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Limited to a 30 day supply of Prescription Drugs.
    Non Preferred Brand Drugs
    • CoPay: $70.00 Copay after deductible
    • 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 Copay after deductible
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Limited to a 30 day supply of Prescription Drugs.

    Inpatient Coverage

    Hospital Services
    • CoPay: Not Applicable
    • CoInsurance: 20.00% Coinsurance after deductible
    • 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: Not Applicable
    • CoInsurance: 20.00% Coinsurance after deductible
    • Covered: Covered

    Emergency and Urgent Care

    Emergency Room
    • CoPay: $350.00 Copay after deductible
    • CoInsurance: Not Applicable
    • Covered: Covered
    Urgent Care Facility
    • CoPay: $90.00
    • CoInsurance: Not Applicable
    • Covered: Covered

    Maternity

    Labor and Delivery Hospital Stay
    • CoPay: Not Applicable
    • CoInsurance: 20.00% Coinsurance after deductible
    • 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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