CommunityCare Gold L21 Select Plus – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay

SKU: 98905OK0130041 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $4,000 per person $4,000 per person
Out-of-pocket max $8,300 per person $17,100 per family
Metal tier Gold

Visit Copay

Primary care visit $30 copay
Specialist visit $50 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
Emergency room 20% coinsurance after deductible
Ambulance $50 copay after deductible
Hospital stay (facility) 20% coinsurance after deductible
Hospital stay (physician) 20% coinsurance after deductible
Outpatient procedure (facility) 20% coinsurance after deductible
Outpatient procedure (physician) 20% coinsurance after deductible
Physical rehabilitation 20% coinsurance

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $10 copay
Brand $45 copay
Non-preferred Brand $95 copay after deductible
Specialty $300 copay after deductible

Lab Tests and Diagnostic Procedures

X-rays 20% coinsurance
Imaging (CT/PET/MRI) 20% coinsurance after deductible
Blood work 20% coinsurance

Mental and Psychiatric Health Care

Mental Health outpatient services 20% coinsurance after deductible
Psychiatric hospital stay 20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.ccok.com/pdf/marketplace/SBC/2024/98905OK0130041-01.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