CareSource Kentucky Co.

Bronze First 7500 $25 Generic Drugs

Prescription Drug Information

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $7,500 Family: $15,000 Per Person: $7,500
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,200 Family: $18,400 Per Person: $9,200
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $50.00
Specialist	Standard: $100.00

Prescription Drug Information

Preferred Brand Drugs	Standard: $50.00 Copay after deductible
Non Preferred Brand Drugs	Standard: $100.00 Copay after deductible
Generic Drugs	Standard: $25.00
Specialty Drugs	Standard: $500.00 Copay after deductible

Emergency and Urgent Care

Emergency Room

Standard: Not Applicable