ConnectiCare Benefits

Choice Gold Alternative POS with Dental

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $3,500 Family: $7,000 Per Person: $3,500
Prescription Drug Deductible	Individual: Included in medical Family: Included in medical Per Person: Included in medical
Medical Out-of-Pocket Maximum	Individual: $7,800 Family: $15,600 Per Person: $7,800
Drug Out-of-Pocket Maximum	Individual: Included in medical Family: Included in medical Per Person: Included in medical

Office Visit

Primary Doctor	Standard: $30 Copay
Specialist	Standard: $50 Copay

Inpatient Coverage

Hospital Services

Standard: 20% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: 20% Coinsurance after deductible

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