CareFirst BlueCross BlueShield

BlueChoice HMO Gold $1,750

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Plan Overview

Medical Deductible	Individual: $1,750 Family: $3,500 Per Person: $1,750
Prescription Drug Deductible	Individual: $150 Family: not applicable Per Person: $150
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,650 Family: $13,300 Per Person: $6,650

Office Visit

Primary Doctor	CoPay: No Charge CoInsurance: No Charge Covered: Covered
Specialist	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $70.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: No Charge CoInsurance: No Charge Covered: Covered
Specialty Drugs	CoPay: $150.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $450.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: $30.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $300.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $450.00 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 : Exam(s) per Benefit Period
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible 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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