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Plan Details

98905OK0180069-00

Plan Year:

2017

Individual Deductible:	$3,000
Individual Out of Pocket Maximum:	$4,500
Office Visit Copay:	$25^*
Preferred Generics:	$15^*
Preferred Brand Name:	$40^*
Non-Preferred Brand Name:	$70^*
Specialty:	$160^*

^*Subject to the deductible.

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Benefit Details

Summary of Benefits and Coverage (SBC)
Medical Benefits
Prescription Drug Benefits

Directories

Provider and Pharmacy Directory

Additional Information

Formulary
Member Handbook
Rx Plan Changes Notice
Rx Copay Changes
Value Added Services
Wellness Resources

Essential Benefits

All health plans in the exchanges are required to provide a minimum set of benefits which are termed essential benefits. These benefits include:

Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health services
Substance use disorder services
Prescription drug coverage
Rehabilitative and habilitative services and devices
Preventative and wellness services
Pediatric Services

Plan Details

CommunityCare Silver 4 Standard

Benefit Details

Directories

Additional Information

Essential Benefits