CareSource West Virginia Co.

CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $6,500.00 Family: $13,000 Per Person: $6,500
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700.00 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 45.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $500.00 Copay per Stay after deductible CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: $500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department.
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Pre and Postnatal Office Visit	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $0.00
CoInsurance: 0.00%
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year
Routine Dental Checkups for Adults	CoPay: $0.00 CoInsurance: Not Applicable Covered: Not Covered

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