CareSource

CareSource Marketplace Standard Silver Dental, Vision & Fitness

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $5,800 Family: $11,600 Per Person: $5,800
Prescription Drug Deductible	Individual: Included in Deductible Family: Included in Deductible Per Person: Included in Deductible
Medical Out-of-Pocket Maximum	Individual: $7,900 Family: $15,800 Per Person: $7,900
Drug Out-of-Pocket Maximum	Individual: Included in Deductible Family: Included in Deductible Per Person: Included in Deductible

Office Visit

Primary Doctor	Standard: $25 Copay
Specialist	Standard: $60 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $50
Non Preferred Brand Drugs	Standard: 25% Coinsurance after deductible
Generic Drugs	Standard: $20
Specialty Drugs	Standard: 45% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: $500 Copay per Stay after deductible
Inpatient Services	Standard: $500 Copay after deductible

Emergency and Urgent Care

Emergency Room

Standard: $500 Copay after deductible

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