CareSource Kentucky Co.

Core Silver 5000 $3 Generic Drugs

Prescription Drug Information

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $5,000 Family: $10,000 Per Person: $5,000
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,500 Family: $17,000 Per Person: $8,500
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $30.00
Specialist	Standard: $70.00

Prescription Drug Information

Preferred Brand Drugs	Standard: $70.00
Non Preferred Brand Drugs	Standard: 40.00% Coinsurance after deductible
Generic Drugs	Standard: $3.00
Specialty Drugs	Standard: 50.00% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $450.00 Copay after deductible