Plan Details

CommunityCare PPO Gold B19 Select

87698OK0090028-00

Plan Year:

2020

Gold Metal plans cover an estimated 80% of your medical and prescription drug costs. They also limit your annual out-of-pocket expenses.

Individual Deductible:	$2,500
Individual Out of Pocket Maximum:	$3,000
Office Visit Copay:	$30
Out of Network Coinsurance:	50%*
Preferred Generics:	$15*
Preferred Brand Name:	$45*
Non-Preferred Brand Name:	$95*
Individual Rx Deductible:	Integrated
Preferred Specialty:	$300*
Non-Preferred Specialty:	$350*

^*Subject to the deductible.

Insure Oklahoma Qualified

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