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Plan Type HMO
Office Visit for Primary Doctor
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No charge after Deductible. The Deductible does not apply to covered preventive services and up to 3 non-preventive primary care visits for Covered Services per Benefit Period.
Office Visit for Specialist No Charge after Deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) No charge after Deductible. The Deductible does not apply to covered preventive services and up to 3 non-preventive primary care visits for Covered Services per Benefit Period.
Annual Deductible Individual: $6,350
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance None
Retail Prescription Drugs Preferred Generic Drugs: No Charge after Deductible
Non-Preferred Generic Drugs: No Charge after Deductible
Preferred Brand Name Drugs: No Charge after Deductible
Non-Preferred Brand Name Drugs: No Charge after Deductible
Specialty Drugs: No Charge after Deductible
Annual Out-of-Pocket Limit Individual: $6,350
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Emergency Care Only. Coverage available in accordance with contract terms. Claims subject to review. 
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room No Charge after Deductible
Emergency Ambulance Services No Charge after Deductible
Urgent Care Facility No Charge after Deductible
Prescription Drug Coverage
Retail Prescription Drugs Preferred Generic Drugs: No Charge after Deductible
Non-Preferred Generic Drugs: No Charge after Deductible
Preferred Brand Name Drugs: No Charge after Deductible
Non-Preferred Brand Name Drugs: No Charge after Deductible
Specialty Drugs: No Charge after Deductible
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Preferred Generic Drugs: No Charge after Deductible
Non-Preferred Generic Drugs: No Charge after Deductible
Preferred Brand Name Drugs: No Charge after Deductible
Non-Preferred Brand Name Drugs: No Charge after Deductible
Specialty Drugs: No Charge after Deductible
Mail Order Supply Up to a 34-day supply (simple Rx) or up to 90-day for maintenance drugs
Outpatient Coverage
Outpatient Surgery No Charge after Deductible
Outpatient Lab/X-Ray No Charge after Deductible
Imaging (CT and PET scans, MRIs) No Charge after Deductible
Outpatient Mental Health No Charge after Deductible
Outpatient Substance Abuse No Charge after Deductible
Outpatient Rehabilitation Services (PT, OT, ST) No Charge after Deductible
Inpatient Coverage
Hospitalization No Charge after Deductible
Skilled Nursing Facility No Charge after Deductible
Inpatient Mental Health No Charge after Deductible
Inpatient Substance Abuse No Charge after Deductible
Home Healthcare No Charge after Deductible
Maternity Coverage
Pre & Postnatal Office Visit No charge after Deductible. The Deductible does not apply to covered preventive services and up to 3 non-preventive primary care visits for Covered Services per Benefit Period.
Labor & Delivery Hospital Stay No Charge after Deductible
Pediatric Services
Dental Checkup for Children No Charge
Vision Screening for Children No Charge
Eye Glasses for Children Pediatric Frame Selection - No Charge
Major Dental Coverage (Pediatric) No Charge after deductible, see details in plan brochure
Additional Coverage
Chiropractic Coverage No Charge after Deductible
Durable Medical Equipment No Charge after Deductible
Hospice No Charge after Deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Exams - No Charge after deductible
Materials - Discounts may be available based on provider
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating NR-5pd as of 05/19/2010
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Summary of Benefits & Coverage

The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

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Important notices and disclaimers

  • The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • CareFirst BlueCross BlueShield - PPO Plans underwritten by Group Hospitalization and Medical Services, Inc. and CareFirst of Maryland, Inc.: BluePreferred HSA Bronze $3,500, BluePreferred HSA Silver $1,500, BluePreferred Gold $500 and BluePreferred Platinum $0.
  • CareFirst BlueCross BlueShield - Point of Service Plans underwritten by CareFirst BlueChoice Inc., for in-network benefits and by Group Hospitalization and Medical Services, Inc. and CareFirst of Maryland, Inc. for out-of-network benefits: BlueChoice Plus Bronze $5,500, BlueChoice Plus Silver $2,500, HealthyBlue Gold $1,500 and HealthyBlue Platinum $0.
  • CareFirst BlueCross BlueShield - HMO Plans underwritten by CareFirst BlueChoice Inc.: BlueChoice Young Adult $6,350, BlueChoice HSA Bronze $6,000, BlueChoice HSA Bronze $4,000, BlueChoice Silver $2,000, BlueChoice HSA Silver $1,300, BlueChoice Gold $1,000 and BlueChoice Gold $0.