Medical & Rx
We offer you a comprehensive benefits program to help you and your family protect your health and financial security. Your benefits are a valuable part of your compensation; we encourage you to learn how your plans work so you can get the most from them.
You have three (3) plan options through CareFirst.
Medical Plan Highlights
This is not a complete list of covered services. For more details, please refer to the plan documents.
BlueChoice HMO HSA Plan
In-Network
Plan Year Deductible1,2 (Individual / Family)
$1,700 / $3,400
Your Coinsurance3
(Plan Pays / You Pay)
100% / 0%
Out-of-Pocket Maximum (Individual / Family)
$4,500 / $7,900
Physician Visit5 (Primary Care / Specialist)
Deductible, then $0 / $5 Copay
Preventive Care Services4
Covered 100%
Lab5, X-Ray or Other Preventative Tests
Deductible, then No Charge
Major Diagnostics (CT/PET, MRI)
Deductible, then No Charge
Hospital Services | Outpatient
Deductible, then No Charge
Hospital Services | Inpatient
Deductible, then No Charge
Urgent Care Visit
Deductible, then No Charge
Emergency Room Visit
Deductible, then No Charge
Vision Exam (1 per year)
$10 Copay
Out-of-Network
Plan Year Deductible1,5 (Individual / Family)
N/A
Your Coinsurance3
(Plan Pays / You Pay)
N/A
Out-of-Pocket Maximum (Individual / Family)
N/A
BlueChoice HMO Plan
In-Network
Plan Year Deductible2 (Individual / Family)
$0 / $0
Your Coinsurance3
(Plan Pays / You Pay)
100% / 0%
Out-of-Pocket Maximum (Individual / Family)
$2,000 / $4,000
Physician Visit5 (Primary Care / Specialist)
$30 / $40 Copay
Preventive Care Services4
Covered 100%
Lab5, X-Ray or Other Preventative Tests
No Charge
Major Diagnostics (CT/PET, MRI)
No Charge
Hospital Services | Outpatient
No Charge
Hospital Services | Inpatient
$300 Copay
Urgent Care Visit
$40 Copay
Emergency Room Visit
$50 Copay
Vision Exam (1 per year)
$10 Copay
Out-of-Network
Plan Year Deductible1,5 (Individual / Family)
N/A
Your Coinsurance3
(Plan Pays / You Pay)
N/A
Out-of-Pocket Maximum (Individual / Family)
N/A
BlueChoice Adv. 2.0 POS Plan
In-Network
Plan Year Deductible2 (Individual / Family)
$500 / $1,000
Your Coinsurance3
(Plan Pays / You Pay)
100% / 0%
Out-of-Pocket Maximum (Individual / Family)
$2,000 / $4,000
Physician Visit5 (Primary Care / Specialist)
$20 / $30 Copay
Preventive Care Services4
Covered 100%
Lab5, X-Ray or Other Preventative Tests
No Charge
Major Diagnostics (CT/PET, MRI)
No Charge
Hospital Services | Outpatient
Deductible, then No Charge
Hospital Services | Inpatient
Ded., then $300 Copay ($1,500 Max)
Urgent Care Visit
$50 Copay
Emergency Room Visit
Deductible, then $250 Copay
Vision Exam (1 per year)
$10 Copay
Out-of-Network
Plan Year Deductible1,5 (Individual / Family)
$1,000 / $2,000
Your Coinsurance3
(Plan Pays / You Pay)
80% / 20%
Out-of-Pocket Maximum (Individual / Family)
$3,000 / $6,000
- When enrolling in the HSA Plan, all covered services are subject to the deductible except Preventive Care services.
- The deductible year runs on the plan year (resets on July 1).
- The amount you pay after the deductible is reached. Your coinsurance kicks in once the calendar year deductible is met.
- Preventive care services include but are not limited to routine wellness exams, pelvic exams, pap testing, PSA tests, and immunizations. Covers preventive care services rendered in a physician's office and outpatient service centers.
- Labcorp Only.
Prescription (Rx) Plan Design
For more details, please refer to the plan document.
BlueChoice HMO HSA Plan
RETAIL (34-DAY SUPPLY)
Rx Calendar Year Deductible (Individual / Family)
Combined w/ Medical
Tier 1 - Generic
Deductible, then $15 copay
Tier 2 - Preferred Brand
Deductible, then $35 copay
Tier 3 - Non-Preferred Brand
Deductible, then $60 copay
Tier 4 - Specialty Preferred Brand
Deductible, then 50% ($100 max)
Tier 4 - Specialty Non-Preferred Brand
Deductible, then 50% ($150 max)
MAIL ORDER (90-DAY SUPPLY)
Tier 1 - Generic
Deductible, then $30 copay
Tier 2 - Preferred Brand
Deductible, then $70 copay
Tier 3 - Non-Preferred Brand
Deductible, then $120 copay
Tier 4 - Specialty Preferred Brand
Deductible, then 50% ($200 max)
Tier 4 - Specialty Non-Preferred Brand
Deductible, then 50% ($300 max)
BlueChoice HMO Plan
RETAIL (34-DAY SUPPLY)
Rx Calendar Year Deductible (Individual / Family)
N/A
Tier 1 - Generic
$15 copay
Tier 2 - Preferred Brand
$35 copay
Tier 3 - Non-Preferred Brand
$60 copay
Tier 4 - Specialty Preferred Brand
50% Coinsurance ($100 max)
Tier 4 - Specialty Non-Preferred Brand
50% Coinsurance ($150 max)
MAIL ORDER (90-DAY SUPPLY)
Tier 1 - Generic
$30 copay
Tier 2 - Preferred Brand
$70 copay
Tier 3 - Non-Preferred Brand
$120 copay
Tier 4 - Specialty Preferred Brand
50% Coinsurance ($200 max)
Tier 4 - Specialty Non-Preferred Brand
50% Coinsurance ($300 max)
BlueChoice Adv. 2.0 POS Plan
RETAIL (34-DAY SUPPLY)
Rx Calendar Year Deductible (Individual / Family)
N/A
Tier 1 - Generic
$15 copay
Tier 2 - Preferred Brand
$35 copay
Tier 3 - Non-Preferred Brand
$60 copay
Tier 4 - Specialty Preferred Brand
50% Coinsurance ($100 max)
Tier 4 - Specialty Non-Preferred Brand
50% Coinsurance ($150 max)
MAIL ORDER (90-DAY SUPPLY)
Tier 1 - Generic
$30 copay
Tier 2 - Preferred Brand
$70 copay
Tier 3 - Non-Preferred Brand
$120 copay
Tier 4 - Specialty Preferred Brand
50% Coinsurance ($200 max)
Tier 4 - Specialty Non-Preferred Brand
50% Coinsurance ($300 max)
Contribution Rates
Semi-Monthly Pre-Tax Contributions (24 Pay Periods)
Payroll Rates
Semi-Monthly Pre-Tax Contributions (24 Pay Periods)
Employee Only
CareFirst BlueChoice HSA HMO Plan
$0.00
CareFirst BlueChoice HMO Plan
$20.72
CareFirst BlueChoice Advantage 2.0 POS Plan
$48.85
Employee + Spouse
CareFirst BlueChoice HSA HMO Plan
$280.01
CareFirst BlueChoice HMO Plan
$296.37
CareFirst BlueChoice Advantage 2.0 POS Plan
$356.63
Employee + Child(ren)
CareFirst BlueChoice HSA HMO Plan
$224.97
CareFirst BlueChoice HMO Plan
$238.49
CareFirst BlueChoice Advantage 2.0 POS Plan
$286.52
Family
CareFirst BlueChoice HSA HMO Plan
$340.89
CareFirst BlueChoice HMO Plan
$361.20
CareFirst BlueChoice Advantage 2.0 POS Plan
$354.09
Contact the provider of these benefits by calling this phone number or visiting this website: 866-520-6099, www.carefirst.com