CommunityCare Marketplace Plan

Plan Brochure

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.

	In Network
MRI, CT Scan and PET Scan	25%^*Coinsurance
Radiology	25%^*Coinsurance
Laboratory	25%^*Coinsurance
Mental Health Physician Visit	$30Copayment per Visit
Inpatient Hospital	25%^*Coinsurance
Urgent Care	$45Copayment per Visit
Emergency Room	25%^*Coinsurance
Preventive Care	No Copayment
Specialty Care Office Visits	$60Copayment per Visit
Primary Care Office Visits	$30Copayment per Visit
Family Out of Pocket Maximum	$15,600
Individual Out of Pocket Maximum	$7,800
Family Deductible	$3,000
Individual Deductible	$1,500

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


Combined Pharmacy and Medical Individual Out-of-Pocket Maximum	$7,800
Combined Pharmacy and Medical Family Out-of-Pocket Maximum	$15,600
Retail Pharmacy - Tier1 - Preferred Generic Drugs	$15
Retail Pharmacy - Tier 2 - Preferred Brand Drugs	$30
Retail Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs	$60
Retail Pharmacy - Diabetic, Ostomy, and Urologic Supplies	25%^†
Mail Order Pharmacy - Tier 1 - Preferred Generic Drugs	$30
Mail Order Pharmacy - Tier 2 - Preferred Brand Drugs	$90
Mail Order Pharmacy - Tier 3 - Non-Preferred Brand or Generic Drugs	$180
Mail Order Pharmacy - Diabetic, Ostomy, and Urologic Supplies	25%^†
Specialty Pharmacy - Tier 4 - Preferred Specialty Pharmacy Drugs	$250

^†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: