Welcome to BlueChoice HMO Individual and Family Plan by CareFirst BlueCross Blue Shield $20 / $30 Copay Plan
This plan is the most affordable of the series. Like the other BlueChoice individual options the is no medical deductible to be met and the plan covers Lab and Xray with no copay. Consider that this plan offers only a $500 prescription annual benefit. Maternity and Dental benefits are optional with this plan as they are with the others in the BlueChoice individual series for Washington DC.
BlueChoice Washington DC Quotes
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District of Columbia Medically Underwritten BlueChoice |
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BlueChoice HMO Washington DC $20 / $30 copay Plan |
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Services |
$20/$30 Copay Option |
General Information |
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Member Deductible |
$0 |
| Out-of-Pocket Maximum |
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| Individual |
$3,600 |
| Individual &Child(ren)*/ Individual & Adult** |
$7,200 |
| Family |
$11,000 |
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Lifetime Maximum |
No lifetime maximum |
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Outpatient Medical and Surgical Services |
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Physician Office Visit for Illness |
$20 PCP/$30 Specialist |
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Rehabilitative Services (Physical, Occupational and Speech Therapy) 30 visits each per calendar year |
$20 PCP/$30 Specialist |
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Surgical Services-Professional |
$20 PCP/$30 Specialist |
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Surgical Services-Hospital or
Other Facility |
$50 facility copayment plus
$20 PCP/ $30 Specialist copay (if applicable) |
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Diagnostic Procedures |
$20 PCP/$30 Specialist |
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X-Rays and Lab Tests |
No copay |
| Prescription Drug Benefits At A Glance |
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Services |
$20/$30 Option |
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Annual Deductible |
$150 |
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Generic copay |
$10 |
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Preferred Brand copay |
$25 |
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Non-Preferred Brand copay |
$40 |
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Annual Drug benefit maximum |
$500 |
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Services |
$20/$30 Option |
| Preventive Services and Office Visits |
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Well Child - Exams & Immunizations
through age 17 |
$20 PCP/$30 Specialist |
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Adult Routine Preventive Health |
$20 PCP/$30 Specialist |
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Routine Gynecological Visits
(No charge for Pap Smear) |
$20 PCP/$30 Specialist |
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Prostate Screening Visits
(No charge for PSA test) |
$20 PCP/$30 Specialist |
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Mammography Screening Visits |
No copay |
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Allergy Testing and Treatment |
$20 PCP/$30 Specialist |
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Annual Routine Eye Exam -at designated Davis Vision provider (optometrists or ophthalmologists) |
$10 |
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Hearing Screening |
$20 PCP/$30 Specialist |
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Inpatient Hospital Services |
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365 Days Room and Board (Semi-Private Room) |
$700 facility copay per admission |
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Medical and Surgical Services |
No copay |
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Prescription Drugs (Inpatient) |
No copay |
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Emergency or Urgent Care |
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Plan-Affiliated Urgent Care Facility |
$30 |
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Hospital Emergency Room or
Non-Plan Facility (Waived if Admitted) |
$50 |
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Ambulance (When Medically Necessary) |
No copay |
