Capital BlueCross

Silver PPO 3500/0/40 Rx 250

Prescription Drug Information

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: $250 Family: $500 Per Person: $250
Medical Out-of-Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700
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: $75 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $55 Copay after deductible
Non Preferred Brand Drugs	Standard: $80 Copay after deductible
Generic Drugs	Standard: $7 Copay
Specialty Drugs	Standard: 20% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: $125 Copay per day after deductible
Inpatient Services	Standard: No Charge after deductible

Emergency and Urgent Care

Emergency Room

Standard: $400 Copay after deductible