ConnectiCare Insurance Company, Inc.

Value Silver Standard POS

Prescription Drug Information

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $5,000 Family: $10,000 Per Person: $5,000
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: $60.00 Copay, deductible does not apply

Prescription Drug Information

Preferred Brand Drugs	Standard: $45.00 Copay after Prescription Drug deductible
Generic Drugs	Standard: $10.00 Copay, deductible does not apply
Specialty Drugs	Standard: 20.00% Coinsurance after Prescription Drug deductible to a maximum of $200 per prescription

Emergency and Urgent Care

Emergency Room

Standard: $450.00 Copay after deductible