CareSource Kentucky Co.

Diabetes Silver 4000 $0 Select Drugs & Specialized Services Adult Vision & Fitness

Prescription Drug Information

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $4,000 Family: $8,000 Per Person: $4,000
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,800 Family: $17,600 Per Person: $8,800
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: $50.00

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: $600.00 Copay after deductible