Capital BlueCross

Silver Capital Advantage EPO 6000/20/40

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: 6000 Family: 12000 Per Person: 6000
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: 8550 Family: 17100 Per Person: 8550
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $40 Copay
Specialist	Standard: $85 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $50 Copay after deductible
Non Preferred Brand Drugs	Standard: $100 Copay after deductible
Generic Drugs	Standard: $10 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 20% Coinsurance after deductible
Inpatient Services	Standard: 20% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $400 Copay after deductible

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