CommunityCare Marketplace Plan

Plan Brochure

Plan Year:

2025

Metal Level:

Silver

Silver Metal plans cover an estimated 70% of your medical and prescription drug costs. They limit your annual out-of-pocket expenses.

	In Network
Individual Deductible	$3,000
Family Deductible	$6,000
Individual Out of Pocket Maximum	$6,400
Family Out of Pocket Maximum	$12,800
Primary Care Office Visits	$40Copayment per Visit
Specialty Care Office Visits	$80Copayment per Visit
Preventive Care	No Copayment
Emergency Room	40%^*Coinsurance
Urgent Care	$60Copayment per Visit
Inpatient Hospital	40%^*Coinsurance
Mental Health Physician Visit	$40Copayment per Visit
Laboratory	40%^*Coinsurance
Radiology	40%^*Coinsurance
MRI, CT Scan and PET Scan	40%^*Coinsurance

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


Combined Pharmacy and Medical Individual Deductible	$3,000
Combined Pharmacy and Medical Family Deductible	$6,000
Combined Pharmacy and Medical Individual Out-of-Pocket Maximum	$6,400
Combined Pharmacy and Medical Family Out-of-Pocket Maximum	$12,800
Retail Pharmacy - Tier1 - Preferred Generic Drugs	$20
Retail Pharmacy - Tier 2 - Preferred Brand Drugs	$40
Retail Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs	$80^*
Retail Pharmacy - Diabetic, Ostomy, and Urologic Supplies	40%^†
Mail Order Pharmacy - Tier 1 - Preferred Generic Drugs	$60
Mail Order Pharmacy - Tier 2 - Preferred Brand Drugs	$120
Mail Order Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs	$240^*
Mail Order Pharmacy - Diabetic, Ostomy, and Urologic Supplies	40%^†
Specialty Pharmacy - Tier 4 - 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: