Community Premier Gold 021 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $45 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | Success
Your progress has been saved. We have sent an email to with a link to continue your application × |
| Out-of-pocket max | $8,700 per person $17,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $45 copay |
| Emergency room | 25% coinsurance after deductible |
| Ambulance | $60 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 | $30 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 25% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | Share |
| Brand | $30 copay |
| Non-preferred Brand | $60 copay |
| Specialty | $250 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 25% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | 25% coinsurance 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/2023/06/27248TX0010021-01-2024.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/ |
