Community Premier Silver 004 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$3,300 per person $3,300 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 copay
Specialist visit	$60 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$60 copay
Emergency room	40% coinsurance after deductible
Ambulance	$60 copay after deductible
Hospital stay (facility)	40% coinsurance after deductible
Hospital stay (physician)	No charge after deductible
Outpatient procedure (facility)	40% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	$60 copay after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	Share
Brand	$70 copay after deductible
Non-preferred Brand	$110 copay after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	$30 copay after deductible
Imaging (CT/PET/MRI)	40% coinsurance after deductible
Blood work	$30 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	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.communityhealthchoice.org/wp-content/uploads/2023/06/27248TX0010004-01-2024.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/