D.C. Options
Deductible Coinsurance Out of Pocket Maximum
In-Network Out of Network In-Network Out of Network In-Network Out of Network
$100 $300 90% 70% $2,500 $5,000
$300 $600 80% 60% $2,500 $5,000
$500 $1,000 80% 60% $2,500 $5,000
$750 $1,500 80% 60% $3,500 $7,000
Maryland (Prince Georges & Montgomery Counties) Options
Deductible Coinsurance Out of Pocket Maximum
In-Network Out of Network In-Network Out of Network In-Network Out of Network
$100 $300 90% 70% $2,500 $5,000
$300 $500 80% 60% $2,500 $5,000
$500 $750 80% 60% $2,500 $4,000


Benefit Summary

Benefit / Service Benefits at a Glance
In Network Out of Network
Well Child Care up through age 17.

$ 0 Copay
 

Your selected coinsurance percentage after deductible.
Adult Preventive Physical Exams

$25 Copay
(No Deductible)

Your selected coinsurance percentage after deductible.
OB/GYN Preventive Care $25 Copay
(No Deductible)		 Your selected coinsurance percentage after deductible.
Mammograms, pap tests, and PSA's (Cancer screenings.) $0 Your selected coinsurance percentage after deductible.
Emergency Care - emergency room $50 Copay
Deductible, and Coinsurance.		 Your selected coinsurance percentage after deductible.
365 Days Hospitalization

Your selected coinsurance percentage after deductible.

Your selected coinsurance percentage after deductible.
Inpatient Physician Services

Your selected coinsurance percentage after deductible.

Your selected coinsurance percentage after deductible.
Inpatient/Outpatient surgery

Your selected coinsurance percentage after deductible.

Your selected coinsurance percentage after deductible.
Diagnostic Test & X-rays

Your selected coinsurance percentage after deductible.

Your selected coinsurance percentage after deductible.
Physician Office Visits

$25 Copay
(No Deductible)

Your selected coinsurance percentage after deductible.
Physical Therapy

Your selected coinsurance percentage after deductible.

Your selected coinsurance percentage after deductible.
Prescription Drugs 
($1,500 Annual Benefit Limit per person)

$100 Deductible, then copayment of:

$10 Generic
$25 Preferred Brand
$45 Non-Preferred Brand

This outline is intended as a summary only. For complete details, consult your Benefit Guide.

HOW THE PLAN WORKS

  • You pay the deductible
    (No deductible required for preventive care provided by an in-network doctor.)
     

  • Then Blue Preferred pays a percentage (90%, 80%, 70%, or 60%) of the allowed benefit.  This is the coverage percentage that you initially selected.  When you visit a doctor, you are responsible for paying the difference between the plan allowance and what the provider actually charges.
     

  • Members are responsible for their coinsurance until they reach the out-of-pocket calendar year maximum. 
     

  • Unlike many other plans, your deductible is included as part of your out-of-pocket maximum, which is the maximum a person on your policy spends towards coinsurance and deductibles per year.  Note:  Outpatient mental health coinsurance does not count toward the out-of-pocket maximum.
     

  • After you meet your out-of-pocket-maximum, the plan pays $100% of the allowed benefit for the rest of the calendar year.
     

  • Families never meet more than two individual out-of-pocket maximums per calendar year.

Carry the card that's recognized and accepted
across Maryland and through-out
the United States.