BluePreferred PPO Value Silver 4500
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| Plan Summary | |
|---|---|
| Plan Type | PPO |
|
Office Visit for Primary Doctor
Find Doctors |
Office/Non-hospital: $35 copay, no deductible Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply) |
| Office Visit for Specialist | Office/Non-hospital: $110 copay, no 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: $35 copay, no deductible Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply) |
| Annual Deductible | Individual: $4,500 This deductible does not apply to preventive services, primary care and specialist office visits, urgent care visits, labs/x-rays/ services, generic drugs and other services as noted. |
| Separate Prescription Drugs Deductible | $750 Individual /$1500 Family applies to Preferred Brand, Non-Preferred Brand, Preferred Specialty Drugs and Non-Preferred Specialty drugs. Individual |
| Coinsurance | N/A |
| Retail Prescription Drugs | Preventive Drugs, Diabetic Supplies and Preferred Brand Insulin: No charge, no deductible; Generic Drugs: $25 copay, no deductible; Preferred Brand Drugs: $75 Copay after deductible; Non-Preferred Brand Drugs: $80 Copay after deductible; Preferred Specialty Drugs: $100 Copay after deductible; Non-Preferred Specialty Drugs: $100 Copay after deductible 90 day supply is available at same cost shares as mail order |
| Annual Out-of-Pocket Limit | Individual: $8,500 Includes deductible |
| Lifetime Maximum | Unlimited |
| Health Savings Account (HSA) Eligible | No |
| Out-of-Network Coverage | Yes (Details in plan brochure below) |
| Out-of-Country Coverage | Yes. Coverage available in accordance with contract terms. Claims subject to review. |
| Office Visit | |
| Primary Care Physician Required | No |
| 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: $500 copay after deductible (waived if admitted) Physician charge: no charge, no deductible |
| Emergency Ambulance Services | $350 copay, no deductible |
| Urgent Care Facility | $75 copay, no deductible |
| Prescription Drug Coverage | |
| Retail Prescription Drugs | Preventive Drugs, Diabetic Supplies and Preferred Brand Insulin: No charge, no deductible; Generic Drugs: $25 copay, no deductible; Preferred Brand Drugs: $75 Copay after deductible; Non-Preferred Brand Drugs: $80 Copay after deductible; Preferred Specialty Drugs: $100 Copay after deductible; Non-Preferred Specialty Drugs: $100 Copay after deductible 90 day supply is available at same cost shares as mail order |
| Separate Prescription Drugs Deductible | $750 Individual /$1500 Family applies to Preferred Brand, Non-Preferred Brand, Preferred Specialty Drugs and Non-Preferred Specialty drugs. Individual |
| Mail Order Prescription Drugs | N/A |
| Mail Order Supply | N/A |
| Outpatient Coverage | |
| Outpatient Surgery | Surgical Center/Non-hospital: $150 copay after deductible Hospital: $150 copay after deductible. Additional physician fees may apply |
| Outpatient Lab/X-Ray | Lab (LabCorp Only): $45 copay, no deductible; Lab (Outpatient Hospital): $45 copay, no deductible; X-Ray (Office/Non-hospital): $150 copay, no deductible; X-Ray (Outpatient Hospital): $150 copay, no deductible |
| Imaging (CT and PET scans, MRIs) | Office/Non-hospital: $600 copay after deductible Outpatient Hospital: $600 copay after deductible |
| Outpatient Mental Health | Office visit: $35 copay, no deductible |
| Outpatient Substance Abuse | Office visit: $35 copay, no deductible |
| Outpatient Rehabilitation Services (PT, OT, ST) | Office/Non-hospital: $35 copay, no deductible Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply) |
| Inpatient Coverage | |
| Hospitalization | Hospital charge: $550 copay after deductible; Physician charge: $40 copay, no deductible |
| Skilled Nursing Facility | $150 copay after deductible |
| Inpatient Mental Health | Hospital charge: $550 copay after deductible; Physician charge: $40 copay, no deductible |
| Inpatient Substance Abuse | Hospital charge: $550 copay after deductible; Physician charge: $40 copay, no deductible |
| Home Healthcare | $45 copay after deductible |
| Maternity Coverage | |
| Pre & Postnatal Office Visit | Preventive: No charge, no deductible Non-preventive: $35 copay, no deductible |
| Labor & Delivery Hospital Stay | Hospital charge: $550 copay after deductible; Physician charge: $40 copay, no 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: $35 copay, no deductible Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply) |
| Durable Medical Equipment | 30% 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 | $9,000 per person | $18,000 per group |
| Out-of-Network Annual Coinsurance | N/A |
| Out-of-Network Annual Out-of-Pocket Limit | $17,000 per person | $34,000 per group |
| Additional Information | |
| A.M. Best Rating | NR as of 12/08/2025 |
| Electronic Signature for Application Available | Yes |
| Details and documents about this plan | |
| View Plan Brochure Summary of Benefits & Coverage | |
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 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 - 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.
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