Plan Brochure
CommunityCare Silver 1519
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. This plan does not qualify as creditable coverage.
Medical Benefit
| In Network | No BP Item.
Pharmacy Benefit
| | |
| Combined Pharmacy and Medical Individual Deductible | $2,900 |
| Combined Pharmacy and Medical Family Deductible | $8,700 |
| Combined Pharmacy and Medical Individual Out-of-Pocket Maximum | $7,050 |
| Combined Pharmacy and Medical Family Out-of-Pocket Maximum | $14,000 |
| Retail Pharmacy - Tier1 - Preferred Generic Drugs | $15* |
| Retail Pharmacy - Tier 2 - Preferred Brand Drugs | $40* |
| Retail Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs | $95* |
| Retail Pharmacy - Diabetic, Ostomy, and Urologic Supplies | 30%†Coinsurance |
| Mail Order Pharmacy - Tier 1 - Preferred Generic Drugs | $15* |
| Mail Order Pharmacy - Tier 2 - Preferred Brand Drugs | $40* |
| Mail Order Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs | $95* |
| Mail Order Pharmacy - Diabetic, Ostomy, and Urologic Supplies | 30%†Coinsurance |
| 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
