ConnectiCare Insurance Company, Inc.

Value Gold Standard POS

Prescription Drug Information

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $1,200 Family: $2,400 Per Person: $1,200
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $7,375 Family: $14,750 Per Person: $7,375
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $20.00 Copay, deductible does not apply
Specialist	Standard: $40.00 Copay, deductible does not apply

Prescription Drug Information

Preferred Brand Drugs	Standard: $35.00 Copay, deductible does not apply
Generic Drugs	Standard: $5.00 Copay, deductible does not apply
Specialty Drugs	Standard: 20.00% Coinsurance after Prescription Drug deductible to a maximum of $100 per prescription

Emergency and Urgent Care

Emergency Room

Standard: $400.00 Copay, deductible does not apply