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Non-Integrated Prescription Options
Mid / Large Group Benefit Summaries - District of Columbia

Formulary 4 is a streamlined formulary that offers employees a choice of preferred generic and preferred brand drugs. This simplified, two-tier plan provides a lower cost drug option that includes medications from all medically necessary drug classes.

Benefit summaries are now available for the health plans listed below. Please check the site frequently for summary updates.

Spanish benefit summaries are available upon request. Please contact your CareFirst sales representative for more information.

NOTE: Employers can consult with a CareFirst account executive to explore other plan options that fit their organization's benefit needs.

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Minimum Value plans have other options.

 

OptionsFeaturesPDF Summary
Option A $0 Ded., $10/$25/$45/50%/50% SUM4044
Option B $0 Ded., $0/$50/$75/50%/50% SUM4045
Option C $0 Ded., $15/$35/$60/50%/50% SUM4046
Option D $0 Ded., $15/$45/$70/50%/50% SUM4047
Option E $0 Ded., $15/$50/$100/50%/50% SUM4048
Option F $100 Ded., $15/$35/$60/50%/50% SUM4050
Option G $200 Ded., $15/$35/$60/50%/50% SUM4051
Option H $300 Ded., $15/$35/$60/50%/50% SUM4052


NOTE: These options have restricted generic substitution.

Minimum Value plans have other options.

 

Summary of Formulary 4 Non-Integrated Rx Options
OptionsFeaturesPDF Summary
Option A $0 Ded., $10/$25 SUM5395
Option B $0 Ded., $15/$35 SUM5396
Option C $0 Ded., $20/$60 SUM5397
Option D $200/$400 Brand Ded., $10/$25 SUM5398
Option E $200/$400 Brand Ded., $15/$35 SUM5399
Option F $500/$1,000 Brand Ded., $20/$60 SUM5400
Option G $100/$200 Ded., $15/$35 SUM5401
Option H $250/$500 Ded., $15/$35 SUM5402

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