CommunityCare Silver SLIH223 Select Plus – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $65 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $6,600 per person $6,600 per person |
Out-of-pocket max | $8,900 per person $18,200 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | $35 copay |
Specialist visit | $65 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $50 copay |
Emergency room | 40% coinsurance after deductible |
Ambulance | 40% coinsurance after deductible |
Hospital stay (facility) | 40% coinsurance after deductible |
Hospital stay (physician) | 40% coinsurance after deductible |
Outpatient procedure (facility) | 40% coinsurance after deductible |
Outpatient procedure (physician) | 40% coinsurance after deductible |
Physical rehabilitation | $35 copay |
Maternitowny and Pregnancy
Well baby care | No charge |
Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
Generic | $10 copay |
Brand | $55 copay |
Non-preferred Brand | 40% coinsurance after deductible |
Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
X-rays | 40% coinsurance after deductible |
Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
Blood work | 40% coinsurance after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | 40% coinsurance after deductible |
Psychiatric hospital stay | 40% coinsurance after deductible |
Health Plan Provider Information
Health Plan Benefits | https://www.ccok.com/pdf/marketplace/SBC/2024/98905OK0130051-01.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 |