Plan Details

CommunityCare Multi-Choice MC22A Tier 1

98905OK0270005-00

Plan Year:

2023

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:	$1,000
Individual Out of Pocket Maximum:	$3,000
Office Visit Copay:	$35
Out of Network Coinsurance:	70%*
Preferred Generics:	$15
Preferred Brand Name:	$45
Non-Preferred Brand Name:	50%
Individual Rx Deductible:	None
Preferred Specialty:	50%
Non-Preferred Specialty:	50%*
OON Individual Deductible:	$5,000
OON Family Deductible:	$18,000
OON OOP Individual Deductible:	Unlimited
OON OOP Family Deductible:	Unlimited
OON Office Visit Copay:	70%*
Specialist Copay:	$50
OON Specialist Copay:	70%*
Coinsurance:	50%*

^*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