Plan Brochure
CommunityCare Gold IH221 Select Plus
Plan Year:
2023
Metal Level:
Gold
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: | $1,100 |
| Individual Out of Pocket Maximum: | $8,700 |
| Office Visit Copay: | $30 |
| Preferred Generics: | $15 |
| Preferred Brand Name: | $45 |
| Non-Preferred Brand Name: | $95* |
| Individual Rx Deductible: | Integrated |
| Preferred Specialty: | $300* |
| Non-Preferred Specialty: | $350* |
First 3 telehealth visits at $0.
*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
