CommunityCare Bronze IH223 – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$5,000 per person $5,000 per person
Out-of-pocket max	$7,250 per person $14,600 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	60% coinsurance after deductible
Specialist visit	60% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	60% coinsurance after deductible
Emergency room	60% coinsurance after deductible
Ambulance	60% coinsurance after deductible
Hospital stay (facility)	60% coinsurance after deductible
Hospital stay (physician)	60% coinsurance after deductible
Outpatient procedure (facility)	60% coinsurance after deductible
Outpatient procedure (physician)	60% coinsurance after deductible
Physical rehabilitation	60% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	60% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	50% coinsurance after deductible
Brand	60% coinsurance after deductible
Non-preferred Brand	60% coinsurance after deductible
Specialty	60% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	60% coinsurance after deductible
Imaging (CT/PET/MRI)	60% coinsurance after deductible
Blood work	60% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	60% coinsurance after deductible
Psychiatric hospital stay	60% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.ccok.com/pdf/marketplace/SBC/2024/98905OK0130045-01.pdf
Drug and medication plan formulary	http://marketplace.ccok.com/?rxFormulary=2&planyear=2024
Search doctor list	https://marketplace.ccok.com?directory=4&planyear=2024