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BlueChoice HMO HSA Bronze $6,150 Virtual Connect
Plan Summary
Plan Type HMO
Office Visit for Primary Doctor
Find Doctors 		Office/Non-hospital: Virtual Connect Plus through selected providers, including Closeknit - No charge* after deductible (carefirst.com/virtualconnect) All other providers - $30 copay, after deductible
Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Office Visit for Specialist Office/Non-hospital: $40 copay after deductible
Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Office Visit for Other Practitioner (Nurse, Physician Assistant) Office/Non-hospital: $30 copay after deductible
Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Annual Deductible Individual: $6,150
This deductible does not apply to preventive services.
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance N/A
Retail Prescription Drugs Preventive Drugs: No charge, no deductible;
Diabetic Supplies and Preferred Brand Insulin: No charge no deductible;
Generic Drugs: $10 copay after deductible;
Preferred Brand Drugs: $50 Copay after deductible;
Non-Preferred Brand Drugs: $70 Copay after deductible;
Preferred Specialty Drugs: $100 Copay after deductible;
Non-Preferred Specialty Drugs: $150 Copay after deductible
90 day supply is available at same cost shares as mail order
Annual Out-of-Pocket Limit Individual: $7,200
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, no deductible
Periodic OB-GYN Exam no charge, no deductible
Well Baby Care no charge, no deductible
Emergency and Urgent Care
Emergency Room Hospital charge: $300 copay after deductible (waived if admitted);
Physician charge: $40 copay after deductible
Emergency Ambulance Services $40 copay after deductible
Urgent Care Facility $60 copay after deductible
Prescription Drug Coverage
Retail Prescription Drugs Preventive Drugs: No charge, no deductible;
Diabetic Supplies and Preferred Brand Insulin: No charge no deductible;
Generic Drugs: $10 copay after deductible;
Preferred Brand Drugs: $50 Copay after deductible;
Non-Preferred Brand Drugs: $70 Copay after deductible;
Preferred Specialty Drugs: $100 Copay after deductible;
Non-Preferred Specialty Drugs: $150 Copay after deductible
90 day supply is available at same cost shares as mail order
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Surgical Center/Non-hospital: $300 copay after deductible
Hospital: $450 copay after deductible. Additional physician fees may apply
Outpatient Lab/X-Ray Lab (LabCorp Only): $25 copay after deductible;
Lab (Outpatient Hospital): $90 copay after deductible;
X-Ray (Office/Non-hospital): $55 copay after deductible;
X-Ray (Outpatient Hospital): $130 copay after deductible
Imaging (CT and PET scans, MRIs) Office/Non-hospital: $250 copay after deductible
Outpatient Hospital: $500 copay after deductible
Outpatient Mental Health Office visit: Virtual Connect Plus through selected providers, including Closeknit - No charge* after deductible (carefirst.com/virtualconnect) All other providers - $30 copay after deductible
Outpatient Substance Abuse Office visit: Virtual Connect Plus through selected providers, including Closeknit - No charge* after deductible (carefirst.com/virtualconnect) All other providers - $30 copay after deductible
Outpatient Rehabilitation Services (PT, OT, ST) Office/Non-hospital: $40 copay after deductible
Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Inpatient Coverage
Hospitalization Hospital charge: $500 copay per day after deductible (up to a copay maximum of $2,500);
Physician charge: $40 copay after deductible.
Skilled Nursing Facility $100 copay per admission after deductible
Inpatient Mental Health Hospital charge: $500 copay per day after deductible (up to a copay maximum of $2,500);
Physician charge: $40 copay after deductible.
Inpatient Substance Abuse Hospital charge: $500 copay per day after deductible (up to a copay maximum of $2,500);
Physician charge: $40 copay after deductible.
Home Healthcare No charge after deductible
Maternity Coverage
Pre & Postnatal Office Visit Preventive: No charge, no deductible
Non-preventive: $30 copay after deductible
Labor & Delivery Hospital Stay Hospital charge: $500 copay per day after deductible (up to a copay maximum of $2,500);
Physician charge: $40 copay after deductible.
Pediatric Services
Dental Checkup for Children No charge, no deductible
Vision Screening for Children No charge, no deductible
Eye Glasses for Children No charge, no deductible
Major Dental Coverage (Pediatric) Surgical: 20% coinsurance after dental deductible
Restorative: 50% coinsurance after dental deductible
Additional Coverage
Chiropractic Coverage Office/Non-hospital: $40 copay after deductible
Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Durable Medical Equipment 20% coinsurance after deductible
Hospice No charge after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Routine Eye Exam: No charge, no deductible
Out-of-Network Coverage
Out-of-Network Authorization Required No
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 as of 05/03/2025
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) 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 can be found at healthcare.gov. 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 - Preferred Provider Organization (PPO) plans are underwritten by Group Hospitalization and Medical Services, Inc. or CareFirst of Maryland, Inc. Point of Service (POS) plans are underwritten by CareFirst BlueChoice Inc., for in-network benefits and by Group Hospitalization and Medical Services, Inc. or CareFirst of Maryland, Inc. for out-of-network benefits. Health Maintenance Organization (HMO) plans are underwritten by CareFirst BlueChoice, Inc.
  • CareFirst BlueCross BlueShield - 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.