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

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% SUM4063
Option B $0 Ded., $0/$50/$75/50%/50% SUM4064
Option C $0 Ded., $15/$35/$60/50%/50% SUM4065
Option D $0 Ded., $15/$45/$70/50%/50% SUM4066
Option E $0 Ded., $15/$50/$100/50%/50% SUM4067
Option F $100 Ded., $15/$35/$60/50%/50% SUM4069
Option G $200 Ded., $15/$35/$60/50%/50% SUM4070
Option H $300 Ded., $15/$35/$60/50%/50% SUM4071


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 SUM5407
Option B $0 Ded., $15/$35 SUM5408
Option C $0 Ded., $20/$60 SUM5409
Option D $200/$400 Brand Ded., $10/$25 SUM5410
Option E $200/$400 Brand Ded., $15/$35 SUM5411
Option F $500/$1,000 Brand Ded., $20/$60 SUM5412
Option G $100/$200 Ded., $15/$35 SUM5413
Option H $250/$500 Ded., $15/$35 SUM5414

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