ConnectiCare Benefits

Choice Gold Alternative POS

Prescription Drug Information

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $2,000 Family: $4,000 Per Person: $2,000
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $7,900 Family: $15,800 Per Person: $7,900
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $40.00 Copay, deductible does not apply
Specialist	Standard: $50.00 Copay, deductible does not apply

Prescription Drug Information

Preferred Brand Drugs	Standard: $40.00 Copay, deductible does not apply
Generic Drugs	Standard: $10.00 Copay, deductible does not apply
Specialty Drugs	Standard: 20.00% Coinsurance after Prescription Drug deductible to a maximum of $150 per prescription

Emergency and Urgent Care

Emergency Room

Standard: 30.00% Coinsurance after deductible