CareSource Just4Me

CareSource Marketplace Low Deductible Silver Dental, Vision, & Fitness

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $5,100.00 Family: $10,200 Per Person: $5,100
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,500.00 Family: $15,000 Per Person: $7,500

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 45.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $500.00 Copay per Stay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).
Inpatient Services	CoPay: $500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $400.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Pre and Postnatal Office Visit	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $0.00
CoInsurance: 0.00%
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Exam(s) per Year
Routine Dental Checkups for Adults	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year Benefit Explanation: $1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.

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