CareSource Kentucky Co.

Core Gold 1500 $10 Generic Drugs

Prescription Drug Information

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $1,500 Family: $3,000 Per Person: $1,500
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $7,000 Family: $14,000 Per Person: $7,000
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $20.00
Specialist	Standard: $60.00

Prescription Drug Information

Preferred Brand Drugs	Standard: $50.00
Non Preferred Brand Drugs	Standard: 40.00% Coinsurance after deductible
Generic Drugs	Standard: $10.00
Specialty Drugs	Standard: 50.00% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $400.00 Copay after deductible

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