CareSource West Virginia Co.

Platinum Zero $5 Generic Drugs

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $4,300.00 Family: $8600 Per Person: $4300

Office Visit

Primary Doctor	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Your Prescription Drug benefits may include a Formulary ... which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.
Generic Drugs	CoPay: $5.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: $150.00 CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $350.00 Copay per Stay CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department.
Urgent Care Facility	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $350.00 CoInsurance: Not Applicable Covered: Covered
Pre and Postnatal Office Visit	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: Not Applicable
CoInsurance: 0.00%
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered