Capital BlueCross

Bronze PPO Choice 7100/0/50

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $7,100 Family: $14,200 Per Person: $7,100
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,100 Family: $18,200 Per Person: $9,100
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $50 Copay
Specialist	Standard: $85 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: No Charge after deductible
Non Preferred Brand Drugs	Standard: No Charge after deductible
Generic Drugs	Standard: $10 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: No Charge after deductible
Inpatient Services	Standard: No Charge after deductible

Emergency and Urgent Care

Emergency Room

Standard: $400 Copay after deductible