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BluePreferred PPO Value Silver $4,500
Plan Summary
Plan Type PPO
Metal Level Silver
Office Visit for Primary Doctor
Find Doctors 		Office/Non-hospital: $35 copay, no deductible
Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Office Visit for Specialist Office/Non-hospital: $100 copay, no deductible
Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Office Visit for Other Practitioner (Nurse, Physician Assistant) Office/Non-hospital: $35 copay, no deductible
Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Annual Deductible Individual: $4,500
This deductible does not apply to preventive services.
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance N/A
Retail Prescription Drugs Preventive Drugs, Diabetic Supplies and Preferred Brand Insulin: No charge, no deductible;
Generic Drugs: $25 copay, no deductible;
Preferred Brand Drugs: $75 Copay after deductible;
Non-Preferred Brand Drugs: $80 Copay after deductible;
Preferred Specialty Drugs: $100 Copay after deductible;
Non-Preferred Specialty Drugs: $100 Copay after deductible
90 day supply is available at same cost shares as mail order
Annual Out-of-Pocket Limit Individual: $7,600
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. Coverage available in accordance with contract terms. Claims subject to review. 
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam no charge, no deductible
Periodic OB-GYN Exam no charge, no deductible
Well Baby Care no charge, no deductible
Emergency and Urgent Care
Emergency Room Hospital charge: $500 copay after deductible;
Physician charge: $100 copay after deductible
Emergency Ambulance Services $350 copay, no deductible
Urgent Care Facility $75 copay, no deductible
Prescription Drug Coverage
Retail Prescription Drugs Preventive Drugs, Diabetic Supplies and Preferred Brand Insulin: No charge, no deductible;
Generic Drugs: $25 copay, no deductible;
Preferred Brand Drugs: $75 Copay after deductible;
Non-Preferred Brand Drugs: $80 Copay after deductible;
Preferred Specialty Drugs: $100 Copay after deductible;
Non-Preferred Specialty Drugs: $100 Copay after deductible
90 day supply is available at same cost shares as mail order
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Surgical Center/Non-hospital: $150 copay after deductible
Hospital: $150 copay after deductible. Additional physician fees may apply
Outpatient Lab/X-Ray Lab (Office/Non-Hospital): $80 copay, no deductible;
Lab (Outpatient Hospital): $80 copay, no deductible;
X-Ray (Office/Non-hospital): $150 copay, no deductible;
X-Ray (Outpatient Hospital): $150 copay, no deductible
Imaging (CT and PET scans, MRIs) Office/Non-hospital: $600 copay after deductible
Outpatient Hospital: $600 copay after deductible
Outpatient Mental Health Office visit: $35 copay, no deductible
Outpatient Substance Abuse Office visit: $35 copay, no deductible
Outpatient Rehabilitation Services (PT, OT, ST) Office/Non-hospital: $35 copay, no deductible
Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Inpatient Coverage
Hospitalization Hospital charge: $550 copay after deductible;
Physician charge: $40 copay, no deductible
Skilled Nursing Facility $150 copay after deductible
Inpatient Mental Health Hospital charge: $550 copay after deductible;
Physician charge: $40 copay, no deductible
Inpatient Substance Abuse Hospital charge: $550 copay after deductible;
Physician charge: $40 copay, no deductible
Home Healthcare $45 copay after deductible
Maternity Coverage
Pre & Postnatal Office Visit Preventive: No charge, no deductible
Non-preventive: $35 copay, no deductible
Labor & Delivery Hospital Stay Hospital charge: $550 copay after deductible;
Physician charge: $40 copay, no deductible
Pediatric Services
Dental Checkup for Children No charge, no deductible
Vision Screening for Children No charge, no deductible
Eye Glasses for Children No charge, no deductible
Major Dental Coverage (Pediatric) Surgical: 20% coinsurance after dental deductible
Restorative: 50% coinsurance after dental deductible
Additional Coverage
Chiropractic Coverage Office/Non-hospital: $35 copay, no deductible
Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Durable Medical Equipment 30% coinsurance after deductible
Hospice No charge after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Routine Eye Exam: No charge, no deductible
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $9,000 per person | $18,000 per group
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit $15,200 per person | $30,400 per group
Additional Information
A.M. Best Rating NR as of 03/14/2025
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • CareFirst BlueCross BlueShield - Preferred Provider Organization (PPO) plans are underwritten by Group Hospitalization and Medical Services, Inc. or CareFirst of Maryland, Inc. Point of Service (POS) plans are underwritten by CareFirst BlueChoice Inc., for in-network benefits and by Group Hospitalization and Medical Services, Inc. or CareFirst of Maryland, Inc. for out-of-network benefits. Health Maintenance Organization (HMO) plans are underwritten by CareFirst BlueChoice, Inc.
  • CareFirst BlueCross BlueShield - Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.