Capital BlueCross

Bronze QHDHP PPO Choice 6300/0/50

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: 6300 Family: 12600 Per Person: 6300
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: 7050 Family: 14100 Per Person: 7050
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 after deductible
Specialist	Standard: $85 Copay after deductible, <br>No Charge after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: No Charge after deductible
Non Preferred Brand Drugs	Standard: No Charge after deductible
Generic Drugs	Standard: No Charge after deductible
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: No Charge after deductible

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