Capital BlueCross

Gold PPO 3250/10/25

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $3,250 Family: $6,500 Per Person: $3,250
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,550 Family: $17,100 Per Person: $8,550
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $25 Copay
Specialist	Standard: $45 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $25 Copay after deductible
Non Preferred Brand Drugs	Standard: $75 Copay after deductible
Generic Drugs	Standard: $10 Copay
Specialty Drugs	Standard: 40% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 10% Coinsurance after deductible
Inpatient Services	Standard: 10% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $350 Copay after deductible

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