CommunityCare Gold IH222 – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $55 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,100 per person $2,100 per person |
| Out-of-pocket max | $8,500 per person $17,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $55 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $300 copay, 30% coinsurance after deductible |
| Ambulance | $50 copay after deductible |
| Hospital stay (facility) | 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $45 copay |
| Non-preferred Brand | $95 copay after deductible |
| Specialty | $300 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | 30% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 30% coinsurance after deductible |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.ccok.com/pdf/marketplace/SBC/2024/98905OK0130044-01.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 |
