Plan Brochure
CommunityCare Silver Standardized
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.
Medical Benefit
| In Network | |
| Individual Deductible | $0 |
| Family Deductible | $0 |
| Individual Out of Pocket Maximum | $2,000 |
| Family Out of Pocket Maximum | $4,000 |
| Primary Care Office Visits | No Copayment |
| Specialty Care Office Visits | $10Copayment per Visit |
| Preventive Care | No Copayment |
| Emergency Room | 25%Coinsurance |
| Urgent Care | $5Copayment per Visit |
| Inpatient Hospital | 25%Coinsurance |
| Mental Health Physician Visit | No Copayment |
| Laboratory | 25%Coinsurance |
| Radiology | 25%Coinsurance |
| MRI, CT Scan and PET Scan | 25%Coinsurance |
Pharmacy Benefit
| | |
| Combined Pharmacy and Medical Individual Out-of-Pocket Maximum | $2,000 |
| Combined Pharmacy and Medical Family Out-of-Pocket Maximum | $4,000 |
| Retail Pharmacy - Tier1 - Preferred Generic Drugs | $0 |
| Retail Pharmacy - Tier 2 - Preferred Brand Drugs | $15 |
| Retail Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs | $50 |
| Retail Pharmacy - Diabetic, Ostomy, and Urologic Supplies | 25%† |
| Mail Order Pharmacy - Tier 1 - Preferred Generic Drugs | $0 |
| Mail Order Pharmacy - Tier 2 - Preferred Brand Drugs | $45 |
| Mail Order Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs | $150 |
| Mail Order Pharmacy - Diabetic, Ostomy, and Urologic Supplies | 25%† |
| Specialty Pharmacy - Tier 4 - Preferred Specialty Pharmacy Drugs | $150 |
†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
