University Community Care Plan by Community First – Gold Plan – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $40 copay
Specialist visit: $65 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $7,250 per person $14,500 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $65 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | $250 copay |
| Ambulance | $250 copay |
| Hospital stay (facility) | $800 copay per Stay |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $125 copay |
| Outpatient procedure (physician) | $600 copay |
| Physical rehabilitation | $125 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $800 copay |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $25 copay |
| Non-preferred Brand | $50 copay |
| Specialty | 30% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $125 copay |
| Imaging (CT/PET/MRI) | $125 copay |
| Blood work | $125 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | $800 copay per Stay |
Health Plan Provider Information
| Health Plan Benefits | https://exchange.communityfirsthealthplans.com/wp-content/uploads/sites/4/2023/08/63251_UCCP-CFIP-2024-Gold-Plan.pdf |
| Drug and medication plan formulary | https://exchange.communityfirsthealthplans.com/wp-content/uploads/sites/4/2022/08/UCCP-Community-First-Insurance-Plan-Formulary.pdf |
| Search doctor list | https://exchange.communityfirsthealthplans.com/wp-content/uploads/sites/4/2023/05/UCCP-ProviderDirectory_Spring2023.pdf |
