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Plan Details

98905OK0170090-00

Plan Year:

2017

Individual Deductible:	$2,500
Individual Out of Pocket Maximum:	$6,850
Office Visit Copay:	$25^‡
Preferred Generics:	$15
Preferred Brand Name:	$60^*
Non-Preferred Brand Name:	$145^*
Specialty:	$280^*
Individual Rx Deductible:	$500

^‡8 visits, combined with specialist, outpatient mental health and urgent care, per year before deductible applies.

^*Subject to the deductible.

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Benefit Details

Directories

Provider and Pharmacy Directory

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 Silver 3 Select

Benefit Details

Directories

Additional Information

Essential Benefits