Plan Brochure
CommunityCare Gold IH221
Plan Year:
2025
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.
Medical Benefit
| In Network | |
| Individual Deductible | $1,100 |
| Family Deductible | $3,300 |
| Individual Out of Pocket Maximum | $8,500 |
| Family Out of Pocket Maximum | $17,000 |
| 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.
Pharmacy Benefit
| | |
| 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 | $8,500 |
| Combined Pharmacy and Medical Family Out-of-Pocket Maximum | $17,000 |
| 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 | 40%* |
*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
