CommunityCare Marketplace Plan

Plan Brochure

CommunityCare Bronze IH224

Plan Year:

2024

Metal Level:

Bronze

Bronze Metal plans cover an estimated 60% of your medical and prescription drug costs. They limit your annual out-of-pocket expenses. Bronze plans are the least expensive of all the "metal plans." Bronze plans do not qualify as creditable coverage.

Medical Benefit

	In Network
Individual Deductible	$7,050
Family Deductible	$14,100
Individual Out of Pocket Maximum	$7,050
Family Out of Pocket Maximum	$14,100
Primary Care Office Visits	No Coinsurance^*
Specialty Care Office Visits	No Coinsurance ^*
Preventive Care	No Copayment
Emergency Room	No Coinsurance ^*
Urgent Care	No Coinsurance ^*
Inpatient Hospital	No Coinsurance ^*
Mental Health Physician Visit	No Coinsurance ^*
Laboratory	No Coinsurance ^*
Radiology	No Coinsurance ^*
MRI, CT Scan and PET Scan	No Coinsurance ^*

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

Pharmacy Benefit


Combined Pharmacy and Medical Individual Deductible	$7,050
Combined Pharmacy and Medical Family Deductible	$14,100
Combined Pharmacy and Medical Individual Out-of-Pocket Maximum	$7,050
Combined Pharmacy and Medical Family Out-of-Pocket Maximum	$14,100
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.

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

Benefit Details

Directories

Additional Information

Plan Options

Base Plan

CommunityCare Bronze IH224 ($7,050/$7,050)
- Plan Brochure
- Summary of Benefits

American Indian Plans

CommunityCare Bronze IH224 ($7,050/$7,050)
- Plan Brochure
- Summary of Benefits
CommunityCare Bronze IH224 ($0/$0)
- Plan Brochure
- Summary of Benefits