BlueChoice HMO Referral
Small Group Off-SHOP - Virginia

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.

BlueChoice HMO Referral

Plan Name Rx Plan Type Integration Status Medical Summary

BlueChoice HMO Referral Platinum 0 Med Ded 25 Dent Ded 

$10/$45/$65/50% (up to $100)/50% (up to $150)

Standard

Integrated OOP ONLY

 SUM7541

SUM7541-SPA

BlueChoice HMO Referral Gold 0 Med Ded 25 Dent Ded 

$10/$45/$65/50% (up to $100)/50% (up to $150)

Standard

Integrated OOP ONLY

 SUM7542

SUM7542-SPA

BlueChoice HMO Referral Gold 800 Med Ded 250 Drug Ded 25 Dent Ded 

$10/D,$45/D,$65/D,50% (up to $100)/D,50% (up to $150)

Standard

Rx DEDUCTIBLE W/INTEGRATED OOP

 SUM7543

SUM7543-SPA

BlueChoice HMO Referral Silver 5350 Med Ded 450 Drug Ded 25 Dent Ded

$15/D,$45/D,$75/D,50% (up to $100)/D,50% (up to $150)

HRA

Rx DEDUCTIBLE W/INTEGRATED OOP

 SUM7544

SUM7544-SPA

BlueChoice HMO Referral Bronze 8900 Med Ded 25 Dent Ded

D,$0/D,$0/D,$0/D,$0/D,$0

HRA

Fully Integrated

 SUM7545

SUM7545-SPA