ConnectiCare Insurance Company, Inc.

Value Bronze Standard POS

Prescription Drug Information

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $6,550 Family: $13,100 Per Person: $6,550
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,100 Family: $18,200 Per Person: $9,100
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: $70.00 Copay after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: $50.00 Copay, deductible does not apply
Generic Drugs	Standard: $15.00 Copay, deductible does not apply
Specialty Drugs	Standard: 50.00% Coinsurance after deductible to a maximum of $500 per prescription

Emergency and Urgent Care

Emergency Room

Standard: $450.00 Copay after deductible