CareSource Kentucky Co.

Low Premium Silver 6000 $3 Generic Drugs

Prescription Drug Information

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $6,000 Family: $12,000 Per Person: $6,000
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,000 Family: $18,000 Per Person: $9,000
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $35.00
Specialist	Standard: $75.00

Prescription Drug Information

Preferred Brand Drugs	Standard: $75.00
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: $500.00 Copay after deductible