CareSource Marketplace Gold Dental and Vision
| Plan Type: | HMO |
| Plan Tier: | Gold |
| Medical Deductible - Individual: | $2,000 |
| Medical Deductible - Family: | $4,000 |
| Drug Deductible - Individual: | Included in Medical |
| Drug Deductible - Family: | Included in Medical |
| Out of Pocket Max - Individual: | $6,500 |
| Out of Pocket Max - Family: | $13,000 |
| Primary Care Visit: | No Charge |
| Specialist Visit: | $35 |
| Emergency Room: | 20% Coinsurance after deductible |
| Hospital - Physician: | 20% Coinsurance after deductible |
| Hospital - Facility: | 20% Coinsurance after deductible |
| Link to Full SBC: | https://www.caresource.com/document/mp-2019-OH-std-goldbase-dv-sum |
| Plan Brochure: | https://www.caresource.com/documents/mp-2019-OH-a-broch |
Other Coverage:
| Child Dental: | Yes |
| Adult Dental | Yes |
Prescription Drug Pricing:
| Generic Drugs: | $10 |
| Non-Preferred Brand Drugs: | $200 |
| Preferred Brand Drugs: | $50 |
| Specialty Drugs: | 40% Coinsurance after deductible |
| Link to Full Policy Formulary: | https://www.caresource.com/documents/2019-OH-marketplace-formulary/ |
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