EOBs for plan members are temporarily unavailable to view online. If you have questions about plan benefits, please contact the CommunityCare customer service team for assistance.

Attention: CommunityCare will be performing systems maintenance Friday, April 19th starting at 5 p.m. through midnight on Saturday, April 20th. Some online documents, tools and resources may be unavailable during this time. Thank you for your patience.

Plan Details

98905OK0170030-00

Plan Year:

2022

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:	$2,000
Individual Out of Pocket Maximum:	$8,500
Office Visit Copay:	$25
Preferred Generics:	$15
Preferred Brand Name:	$40
Non-Preferred Brand Name:	$70
Individual Rx Deductible:	None
Preferred Specialty:	$160
Non-Preferred Specialty:	$210

Benefit Details

Directories

Additional Information

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 Gold 619 Select

Benefit Details

Directories

Additional Information

Essential Benefits