Cost Sharing Benefits (In Network)
Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.
Deductible (Individual) |
$1,000 |
Deductible (Family) |
$2,000 |
Coinsurance |
Not applicable |
Out of Pocket Maximum (Individual) |
$2,500 |
Out of Pocket Maximum (Family) |
$5,000 |
Doctor Visits
Primary Care Visit |
Data Not Available |
Specialist Visit |
Data Not Available |
Inpatient Facility |
$150 Copay per day |
Inpatient Physician |
20% Coinsurance after deductible |
Emergency Room Services |
$250 Copay after deductible |
Tests and Imaging
Imaging (CT/PET Scans, MRIs) |
$150 Copay after deductible |
Laboratory Outpatient and Professional Services |
20% Coinsurance after deductible |
X-Ray and Diagnostic Imaging |
$75 Copay after deductible |
Health Management Programs
Asthma |
Available |
Depression |
Available |
Diabetes |
Available |
Heart Disease |
Available |
High Blood Pressure / High Cholesterol |
Available |
Lower Back Pain |
Available |
Pain Management |
Available |
Pregnancy |
Available |
Weight Loss |
Not available |
Other
Mental / Behavioral Health Inpatient |
$150 Copay per day |
Mental / Behavioral Health Outpatient |
Data Not Available |
Rehabilitative Speech Therapy |
20% Coinsurance after deductible |
Rehabilitative Occupational & Physical Therapy |
20% Coinsurance after deductible |
Outpatient Facility |
20% Coinsurance after deductible |
Outpatient Surgery |
20% Coinsurance after deductible |
Prescription Drugs
Generic Rx |
Data Not Available |
Preferred Brand Rx |
Data Not Available |
Non Preferred Brand Rx |
Data Not Available |
Specialty Drugs
| |
Other Plans in Indiana
Plan
CareSource Silver
|
Deductible
$3,300 |
Coinsurance Not applicable |
Out of Pocket
$6,400 |
Plan
CareSource Federal Simple Choice Gold
|
Deductible
$1,250 |
Coinsurance Not applicable |
Out of Pocket
$4,750 |
Plan
CareSource Bronze
|
Deductible
$6,650 |
Coinsurance Not applicable |
Out of Pocket
$6,850 |
Plan
CareSource Hoosier Choice Bronze
|
Deductible
$6,650 |
Coinsurance Not applicable |
Out of Pocket
$6,850 |
Plan
CareSource Low Premium Silver
|
Deductible
$6,150 |
Coinsurance Not applicable |
Out of Pocket
$7,000 |
Plan
CareSource Hoosier Choice Silver
|
Deductible
$3,300 |
Coinsurance Not applicable |
Out of Pocket
$6,400 |
Plan
CareSource Gold Dental and Vision
|
Deductible
$1,000 |
Coinsurance Not applicable |
Out of Pocket
$2,500 |
Plan
CareSource Hoosier Choice Gold Dental and Vision
|
Deductible
$1,000 |
Coinsurance Not applicable |
Out of Pocket
$2,500 |
Plan
CareSource Bronze Dental and Vision
|
Deductible
$6,650 |
Coinsurance Not applicable |
Out of Pocket
$6,850 |
Plan
CareSource Silver Dental and Vision
|
Deductible
$3,300 |
Coinsurance Not applicable |
Out of Pocket
$6,400 |
Plan
CareSource Federal Simple Choice Silver
|
Deductible
$3,500 |
Coinsurance Not applicable |
Out of Pocket
$7,150 |
Plan
CareSource Hoosier Choice Bronze Dental and Vision
|
Deductible
$6,650 |
Coinsurance Not applicable |
Out of Pocket
$6,850 |
Plan
CareSource Hoosier Choice Silver Dental and Vision
|
Deductible
$3,300 |
Coinsurance Not applicable |
Out of Pocket
$6,400 |
Plan
CareSource Federal Simple Choice Bronze
|
Deductible
$6,650 |
Coinsurance Not applicable |
Out of Pocket
$7,150 |
Plan
CareSource Gold
|
Deductible
$1,000 |
Coinsurance Not applicable |
Out of Pocket
$2,500 |