Plan Brochure
CommunityCare Catastrophic Select
Plan Year:
2024
Metal Level:
Catastrophic
CommunityCare's Fundamental Plan is defined by federal regulation as a "catastrophic plan." As defined by the Affordable Care Act (ACA), a catastrophic plan covers essential health benefits, but only after out-of-pocket cost sharing reaches a high deductible that equals the level of the ACA's required out-of-pocket maximum. Catastrophic plans do not qualify as creditable coverage.
Medical Benefit
| In Network | |
| Individual Deductible | $9,450 |
| Family Deductible | $18,900 |
| Individual Out of Pocket Maximum | $9,450 |
| Family Out of Pocket Maximum | $18,900 |
| Primary Care Office Visits | $35*(limited to the first 3 visits per year, then no copayment after deductible) |
| Specialty Care Office Visits | No Copayment* |
| Preventive Care | No Copayment |
| Emergency Room | No Copayment* |
| Urgent Care | No Copayment* |
| Inpatient Hospital | No Copayment* |
| Mental Health Physician Visit | $35*(limited to the first 3 visits per year, then no copayment after deductible) |
| Laboratory | No Copayment* |
| Radiology | No Copayment* |
| MRI, CT Scan and PET Scan | No Copayment* |
*After Deductible, the Coinsurance/Copayment will apply.
Pharmacy Benefit
| | |
| Combined Pharmacy and Medical Individual Deductible | $9,450 |
| Combined Pharmacy and Medical Family Deductible | $18,900 |
| Combined Pharmacy and Medical Individual Out-of-Pocket Maximum | $9,450 |
| Combined Pharmacy and Medical Family Out-of-Pocket Maximum | $18,900 |
| Retail Pharmacy - Tier1 - Preferred Generic Drugs | $0* |
| Retail Pharmacy - Tier 2 - Preferred Brand Drugs | $0* |
| Retail Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs | $0* |
| Retail Pharmacy - Diabetic, Ostomy, and Urologic Supplies | $0† |
| Mail Order Pharmacy - Tier 1 - Preferred Generic Drugs | $0* |
| Mail Order Pharmacy - Tier 2 - Preferred Brand Drugs | $0* |
| Mail Order Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs | $0* |
| Mail Order Pharmacy - Diabetic, Ostomy, and Urologic Supplies | $0† |
| Specialty Pharmacy - Tier 4 - Preferred Specialty Pharmacy Drugs | $0* |
| Specialty Pharmacy - Tier 5 - Non-Preferred Specialty Pharmacy Drugs | $0* |
*After Deductible, the Coinsurance/Copayment will apply.
†Select supplies will be covered under the applicable formulary tier copay/coinsurance.
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
