Non-Integrated Prescription Options
Mid / Large Group Benefit Summaries - Maryland

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.

 

Summary of Non-Integrated Rx Options
OptionsFeaturesPDF Summary
Option A $0 Ded., $10/$25/$45/50%/50% SUM4025
Option B $0 Ded., $0/$50/$75/50%/50% SUM4026
Option C $0 Ded., $15/$35/$60/50%/50% SUM4027
Option D $0 Ded., $15/$45/$70/50%/50% SUM4028
Option E $0 Ded., $15/$50/$100/50%/50% SUM4029
Option F $100 Ded., $15/$35/$60/50%/50% SUM4031
Option G $200 Ded., $15/$35/$60/50%/50% SUM4032
Option H $300 Ded., $15/$35/$60/50%/50% SUM4033


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 SUM5383
Option B $0 Ded., $15/$35 SUM5384
Option C $0 Ded., $20/$60 SUM5385
Option D $200/$400 Brand Ded., $10/$25 SUM5386
Option E $200/$400 Brand Ded., $15/$35 SUM5387
Option F $500/$1,000 Brand Ded., $20/$60 SUM5388
Option G $100/$200 Ded., $15/$35 SUM5389
Option H $250/$500 Ded., $15/$35 SUM5390

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