BlueChoice HMO HSA Silver $3,300 Med Ded 25 Dent Ded
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| Plan Summary | |
|---|---|
| Plan Type | HMO |
| Metal Level | Silver |
|
Office Visit for Primary Doctor
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Office/Non-hospital: $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: $3,300 This deductible does not apply to preventive services. |
| Separate Prescription Drugs Deductible | Medical Plan Deductible Applies |
| Coinsurance | N/A |
| Retail Prescription Drugs | Non-Maintenance Drugs: Up to a 30-Day Supply; Preventive Drugs: No charge, no deductible; Diabetic Supplies and Preferred Brand Insulin: No charge, no deductible; Non-Preferred Brand Insulin: $30 copay; Generic Drugs: $10 copay after deductible; Preferred Brand Drugs: $50 copay after deductible; Non-Preferred Brand Drugs: $70 copay after deductible Specialty Drugs: Up to a 30-day supply only. Available only through mail order; Preferred Specialty Drugs: $100 copay after deductible; Non-Preferred Specialty Drugs: $150 copay after deductible Maintenance Drugs: Up to a 90-day supply at 2 times the 30-day copay. Available for generic and brand name drugs through retail locations and mail order. |
| Annual Out-of-Pocket Limit | Individual: $6,600 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 | Non-Maintenance Drugs: Up to a 30-Day Supply; Preventive Drugs: No charge, no deductible; Diabetic Supplies and Preferred Brand Insulin: No charge, no deductible; Non-Preferred Brand Insulin: $30 copay; Generic Drugs: $10 copay after deductible; Preferred Brand Drugs: $50 copay after deductible; Non-Preferred Brand Drugs: $70 copay after deductible Specialty Drugs: Up to a 30-day supply only. Available only through mail order; Preferred Specialty Drugs: $100 copay after deductible; Non-Preferred Specialty Drugs: $150 copay after deductible Maintenance Drugs: Up to a 90-day supply at 2 times the 30-day copay. Available for generic and brand name drugs through retail locations and 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: $30 copay after deductible |
| Outpatient Substance Abuse | Office visit: $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: $40 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 06/05/2025 |
| 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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