CareSource Kentucky Co.

HDHP Preventive Silver 5500 $0 Select Drugs

Prescription Drug Information

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $5,500 Family: $11,000 Per Person: $5,500
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $5,500 Family: $11,000 Per Person: $5,500
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: No Charge after deductible
Specialist	Standard: No Charge after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: No Charge after deductible
Non Preferred Brand Drugs	Standard: No Charge after deductible
Generic Drugs	Standard: No Charge after deductible
Specialty Drugs	Standard: No Charge after deductible

Emergency and Urgent Care

Emergency Room

Standard: No Charge after deductible