CommunityCare Marketplace Plan

Plan Brochure

CommunityCare Gold IH221

Plan Year:

2024

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.

	In Network
Individual Deductible	$1,100
Family Deductible	$3,300
Individual Out of Pocket Maximum	$8,700
Family Out of Pocket Maximum	$17,400
Primary Care Office Visits	$30Copayment per Visit
Specialty Care Office Visits	$55Copayment per Visit
Preventive Care	No Copayment
Emergency Room	$300^~Copayment per Visit then 35% Coinsurance
Urgent Care	$50Copayment per Visit
Inpatient Hospital	35%^*Coinsurance
Mental Health Physician Visit	$30Copayment per Visit
Laboratory	40%Coinsurance
Radiology	40%Coinsurance
MRI, CT Scan and PET Scan	35%^*Coinsurance

^~After Copayment the Deductible and Coinsurance applies.

^*After Deductible, the Coinsurance/Copayment will apply.


Combined Pharmacy and Medical Individual Deductible	$1,100
Combined Pharmacy and Medical Family Deductible	$3,300
Combined Pharmacy and Medical Individual Out-of-Pocket Maximum	$8,700
Combined Pharmacy and Medical Family Out-of-Pocket Maximum	$17,400
Retail Pharmacy - Tier1 - Preferred Generic Drugs	$15
Retail Pharmacy - Tier 2 - Preferred Brand Drugs	$45
Retail Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs	$95^*
Retail Pharmacy - Diabetic, Ostomy, and Urologic Supplies	40%^†
Mail Order Pharmacy - Tier 1 - Preferred Generic Drugs	$45
Mail Order Pharmacy - Tier 2 - Preferred Brand Drugs	$135
Mail Order Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs	$285^*
Mail Order Pharmacy - Diabetic, Ostomy, and Urologic Supplies	40%^†
Specialty Pharmacy - Tier 4 - Preferred Specialty Pharmacy Drugs	$300^*
Specialty Pharmacy - Tier 5 - Non-Preferred Specialty Pharmacy Drugs	$350^*

^*After Deductible, the Coinsurance/Copayment will apply.

^†Select supplies will be covered under the applicable formulary tier copay/coinsurance.

All health plans in the exchanges are required to provide a minimum set of benefits which are termed essential benefits. These benefits include: