EOBs for plan members are temporarily unavailable to view online. If you have questions about plan benefits, please contact the CommunityCare customer service team for assistance.

Plan Details

87698OK0110040-00

Plan Year:

2021

Silver Metal plans cover an estimated 70% of your medical and prescription drug costs. They limit your annual out-of-pocket expenses.

Individual Deductible:	$5,500
Individual Out of Pocket Maximum:	$8,000
Office Visit Copay:	$30
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

^*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 Silver B20 Standard

Benefit Details

Directories

Additional Information

Essential Benefits