Community Premier Gold 005 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $40 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | Success
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| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | 25% coinsurance after deductible |
| Ambulance | $40 copay after deductible |
| Hospital stay (facility) | 25% coinsurance after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | 25% coinsurance after deductible |
| Outpatient procedure (physician) | 25% coinsurance after deductible |
| Physical rehabilitation | $40 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 25% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | Share |
| Brand | $50 copay after deductible |
| Non-preferred Brand | $75 copay after deductible |
| Specialty | 35% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $20 copay after deductible |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | $20 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | This is the amount you’re responsible for when receiving services provided by a physician, surgeon, or other specialist. |
| Psychiatric hospital stay | 25% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.communityhealthchoice.org/wp-content/uploads/2023/06/27248TX0010005-01-2024.pdf |
| Drug and medication plan formulary | https://www.communityhealthchoice.org/wp-content/uploads/2023/04/formulary-premier-2024.pdf |
| Search doctor list | https://providersearch.communityhealthchoice.org/ |
