Capital BlueCross

Gold Simple PPO 0/0/25

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $0 Family: $0 Per Person: $0
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: $50 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $45 Copay
Non Preferred Brand Drugs	Standard: $70 Copay
Generic Drugs	Standard: $4 Copay
Specialty Drugs	Standard: 20% Coinsurance

Inpatient Coverage

Hospital Services	Standard: $4000 Copay per stay
Inpatient Services	Standard: No Charge

Emergency and Urgent Care

Emergency Room

Standard: $200 Copay

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