CareSource

CareSource Marketplace Gold Dental, Vision + Fitness

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $2,000 Family: $4,000 Per Person: $2,000
Prescription Drug Deductible	Individual: Included in Deductible Family: Included in Deductible Per Person: Included in Deductible
Medical Out-of-Pocket Maximum	Individual: $6,500 Family: $13,000 Per Person: $6,500
Drug Out-of-Pocket Maximum	Individual: Included in Deductible Family: Included in Deductible Per Person: Included in Deductible

Office Visit

Primary Doctor	Standard: $20 Copay
Specialist	Standard: $50 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $50
Non Preferred Brand Drugs	Standard: 40% Coinsurance after deductible
Generic Drugs	Standard: $15
Specialty Drugs	Standard: 40% 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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