| Medical Deductible | - Individual: $1,750
- Family: $3,500
- Per Person: $1,750
|
| Prescription Drug Deductible | - Individual: $150
- Family: Included in Medical
- Per Person: $150
|
| Medical Out-of-Pocket Maximum | - Individual: $6,650
- Family: $13,300
- Per Person: $6,650
|
| Drug Out-of-Pocket Maximum | - Individual: Included in Medical
- Family: Included in Medical
- Per Person: Included in Medical
|
Prescription Drug Information
| Preferred Brand Drugs | - Standard: $50 Copay after deductible
|
| Non Preferred Brand Drugs | - Standard: $70 Copay after deductible
|
| Generic Drugs | |
| Specialty Drugs | - Standard: $150 Copay after deductible
|
| Hospital Services | - Standard: $450 Copay per day after deductible
|
| Inpatient Services | - Standard: $30 Copay after deductible
|
Emergency and Urgent Care
| Emergency Room | - Standard: $300 Copay after deductible
|
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.
1-817-813-4562, TTY 711
