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BlueChoice HMO Open Access
Mid / Large Group Benefit Summaries - District of Columbia
Benefit summaries are now available for the health plans listed below. Please check the site frequently for summary updates.
Please note: Not all services and procedures are covered by your benefits contract. Benefit summaries are for comparison purposes only and does not create rights not given through the benefit plan.
NOTE: Employers can consult with a CareFirst account executive to explore other plan options that fit their organization's benefit needs.
| Options | Features | Medical Summary | Rx Summary |
|---|---|---|---|
| Option 3 | Copay $10/20 $0 Ded. | CUT8629 | Non-Integrated Rx Options |
| Option 13 | Copay $30/40 $0 Ded. | CUT8639 | Non-Integrated Rx Options |
| Option 14 | Copay $20/30 $0 Ded. | CUT8640 | Non-Integrated Rx Options |
| Option 15 | Copay $20/30 $0 Ded. | SUM5782 | Non-Integrated Rx Options |
| Option 16 | Copay $20/30 $500 Ded. | SUM5783 | Non-Integrated Rx Options |
| Option 17 | Copay $20/30 $1,000 Ded. | SUM5784 | Non-Integrated Rx Options |
| Option 18 | Copay $20/30 $1,500 Ded. | SUM5785 | Non-Integrated Rx Options |
| Option 19 | Copay $20/30 $2,000 Ded. | SUM5786 | Non-Integrated Rx Options |
| Option 20 | Copay $20/30 $2,500 Ded. | SUM5787 | Non-Integrated Rx Options |
| Option B | Copay $20/30 $500 Ded. | CUT8642 | Non-Integrated Rx Options |
| Option C | Copay $30/40 $500 Ded. | CUT8643 | Non-Integrated Rx Options |
| Option I | Copay $30/40 $500 Ded. | CUT8494 | Non-Integrated Rx Options |
| Option J | Copay $30/40 $0 Ded. | CUT8495 | Non-Integrated Rx Options |
| Option M | $20/20% $1,000 Ded. | SUM4635 | Non-Integrated Rx Options |
| Option N | Copay $20/40 $1,500 Ded. | SUM4636 | Non-Integrated Rx Options |
| Option P | Copay $10/20 $500 Ded. | SUM4638 | Non-Integrated Rx Options |
All plans are fully insured. Please consult with your CareFirst sales representative for information about self-insured options.
| Options | Features | Medical Summary | Rx Summary |
|---|---|---|---|
| Option 1-S | $0 Deductible | SUM3296 | Non-Integrated Rx Options |
| Option 2-S | $500 Deductible | SUM3297 | Non-Integrated Rx Options |
| Option 3-S | $1,000 Deductible | SUM3298 | Non-Integrated Rx Options |
| Option 4-S | $2,000 Deductible | SUM3299 | Non-Integrated Rx Options |
| Option 5-S | $1,500 Deductible | SUM4097 | Non-Integrated Rx Options |
All plans are fully insured. Please consult with your CareFirst sales representative for information about self-insured options.
| Options | Features | Medical Summary | Rx Summary |
|---|---|---|---|
| BlueChoice HMO Open Access Option MV 3 |
$3,000 Deductible | SUM5100 | Non-Integrated Minimum Value (MV) Rx Options |
| BlueChoice HMO Open Access Option MV 4 |
$5,000 Deductible | SUM5101 | Non-Integrated Minimum Value (MV) Rx Options |
| BlueChoice HMO Open Access Option MV 5 |
$7,000 Deductible | SUM5102 | Non-Integrated Minimum Value (MV) Rx Options |
| BlueChoice HMO Open Access Option MV 6 |
$3,000 Deductible | SUM6901 | Non-Integrated Minimum Value (MV) Rx Options |
All plans are fully insured. Please consult with your CareFirst sales representative for information about self-insured options.