Attention: CommunityCare will be performing systems maintenance Friday, June 5th starting at 5 p.m. through midnight on Saturday, June 6th. Some online documents, tools and resources may be unavailable during this time. Thank you for your patience.

Plan Details

CommunityCare PPO Gold B19 Standard

87698OK0110029-00
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:250
Preferred Specialty:$300*
Non-Preferred Specialty:$350*
*Subject to the deductible

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
Coronavirus Self-CheckerX