CareSource Kentucky Co.

Diabetes Gold 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness

Prescription Drug Information

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $1,100 Family: $2,200 Per Person: $1,100
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $7,500 Family: $15,000 Per Person: $7,500
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $10.00
Specialist	Standard: $40.00

Prescription Drug Information

Preferred Brand Drugs	Standard: $60.00
Non Preferred Brand Drugs	Standard: 30.00% Coinsurance after deductible
Generic Drugs	Standard: $2.00
Specialty Drugs	Standard: 40.00% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $500.00 Copay after deductible