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Plan Details

87698OK0110029-00

Plan Year:

2023

Gold Metal plans cover an estimated 80% of your medical and prescription drug costs. They also limit your annual out-of-pocket expenses.

Individual Deductible:	$2,500
Individual Out of Pocket Maximum:	$5,000
Office Visit Copay:	$35
Out of Network Coinsurance:	30%^*
Preferred Generics:	$15
Preferred Brand Name:	$45
Non-Preferred Brand Name:	$95^*
Individual Rx Deductible:	Integrated
Preferred Specialty:	$300^*
Non-Preferred Specialty:	$350^*
OON Individual Deductible:	$4,000
OON Family Deductible:	$12,000
OON OOP Individual Deductible:	Unlimited
OON OOP Family Deductible:	Unlimited
OON Office Visit Copay:	30%^†
Specialist Copay:	$55
OON Specialist Copay:	30%^†
Coinsurance:	0%^*

^*Subject to the deductible.

^†First 3 primary care visits have a $35 co-payment and are not subject to the deductible.

Benefit Details

Directories

Additional Information

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

Plan Details

CommunityCare PPO Gold B19 Standard

Benefit Details

Directories

Additional Information

Essential Benefits