Capital Health Plan

HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement)

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: $7,900.00 Family: $15,800 Per Person: $7,900

Office Visit

Primary Doctor	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $65.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $750.00 Copay per Day CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Coinsurance and Copayment is waived if inpatient admission occurs; however if moved to observation status an additional copayment may apply based on services rendered.
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $750.00 CoInsurance: Not Applicable Covered: Covered
Pre and Postnatal Office Visit	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Provided at Capital Health Plan's Eye Care Centers

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered

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