BlueChoice HMO
Mid / Large Group Benefit Summaries - Virginia

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

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

BlueChoice HMO Summary of Plan Options
Options	Features	Medical Summary	Rx Summary
Option 3	Copay $10/20 $0 Ded.	BRC6937	Non-Integrated Rx Options
Option 13	Copay $30/40 $0 Ded.	BRC6957	Non-Integrated Rx Options
Option 14	Copay $20/30 $0 Ded.	BRC6958	Non-Integrated Rx Options
Option 15	Copay $20/30 $0 Ded.	SUM5796	Non-Integrated Rx Options
Option 16	Copay $20/30 $500 Ded.	SUM5797	Non-Integrated Rx Options
Option 17	Copay $20/30 $1,000 Ded.	SUM5798	Non-Integrated Rx Options
Option 18	Copay $20/30 $1,500 Ded.	SUM5799	Non-Integrated Rx Options
Option 19	Copay $20/30 $2,000 Ded.	SUM5800	Non-Integrated Rx Options
Option 20	Copay $20/30 $2,500 Ded.	SUM5801	Non-Integrated Rx Options
Option B	Copay $20/30 $500 Ded.	BRC6960	Non-Integrated Rx Options
Option C	Copay $30/40 $500 Ded.	BRC6961	Non-Integrated Rx Options
Option I	Copay $30/40 $500 Ded.	BRC6892	Non-Integrated Rx Options
Option J	Copay $30/40 $0 Ded.	BRC6893	Non-Integrated Rx Options
Option L	10% $1,000 Ded.	SUM4709	Non-Integrated Rx Options
Option M	$20/20% $1,000 Ded.	SUM4710	Non-Integrated Rx Options
Option N	Copay $20/40 $1,500 Ded.	SUM4711	Non-Integrated Rx Options

All plans are fully insured. Please consult with your CareFirst sales representative for information about self-insured options.

BlueChoice HMO Smart Selections Summary of Plan Options
Options	Features	Medical Summary	Rx Summary
Option 1-S	$0 Deductible	SUM3310	Non-Integrated Rx Options
Option 2-S	$500 Deductible	SUM3311	Non-Integrated Rx Options
Option 3-S	$1,000 Deductible	SUM3312	Non-Integrated Rx Options
Option 5-S	$1,500 Deductible	SUM4102	Non-Integrated Rx Options
Option 6-S	$3,000 Deductible	SUM4103	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 Option MV 1	$4,500 Deductible	SUM2699	Non-Integrated Minimum Value (MV) Rx Options
BlueChoice HMO Option MV 2	$5,000 Deductible	SUM3314	Non-Integrated Minimum Value (MV) Rx Options
BlueChoice HMO Option MV 3	$3,000 Deductible	SUM5110	Non-Integrated Minimum Value (MV) Rx Options
BlueChoice HMO Option MV 4	$5,000 Deductible	SUM5111	Non-Integrated Minimum Value (MV) Rx Options
BlueChoice HMO Option MV 5	$7,000 Deductible	SUM5112	Non-Integrated Minimum Value (MV) Rx Options
BlueChoice HMO Option MV 6	$3,000 Deductible	SUM6909	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.