CareFirst

BlueChoice HMO HSA Silver 3300 Med Ded 25 Dent Ded VisionPlus

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Plan Overview

Medical Deductible	Individual: $3,300 Family: $6,600 Per Person: $3,300
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $6,500 Family: $13,000 Per Person: $6,500
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $30 Copay after deductible
Specialist	Standard: $40 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: $10 Copay after deductible
Specialty Drugs	Standard: $150 Copay after deductible

Inpatient Coverage

Hospital Services	Standard: $500 Copay per day after deductible
Inpatient Services	Standard: $40 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.

BlueChoice HMO HSA Silver 3300 Med Ded 25 Dent Ded VisionPlus

Plan Overview

Office Visit

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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