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.

Plan Details

CommunityCare Multi-Choice MC21B Tier 1

Plan Year:

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:$3,200
Individual Out of Pocket Maximum:$6,400
Office Visit Copay:$20
Out of Network Coinsurance:50%*
Preferred Generics:$10
Preferred Brand Name:$40
Non-Preferred Brand Name:$70
Individual Rx Deductible:None
Preferred Specialty:$160
Non-Preferred Specialty:$210
OON Individual Deductible:$7,500
OON Family Deductible:$17,100
OON OOP Individual Deductible:Unlimited
OON OOP Family Deductible:Unlimited
OON Office Visit Copay:50%*
Specialist Copay:$40
OON Specialist Copay:50%*
*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