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

98905OK0170085-00

Plan Year:

2017

Individual Deductible:	$1,250
Individual Out of Pocket Maximum:	$4,750
Office Visit Copay:	$20
Preferred Generics:	$10
Preferred Brand Name:	$30
Non-Preferred Brand Name:	$75
Specialty:	30%

Click here to visit HealthCare.gov for a Rate Quote

Benefit Details

Summary of Benefits and Coverage (SBC)
Medical Benefits
Prescription Drug Benefits

Directories

Provider and Pharmacy Directory

Additional Information

Formulary
Member Handbook
Rx Copay Changes
Rx Plan Changes Notice
Value Added Services
Wellness Resources

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 4 Classic

Benefit Details

Directories

Additional Information

Essential Benefits