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Plan Details

98905OK0130042-00

Plan Year:

2021

Individual Deductible:	$7,700
Individual Out of Pocket Maximum:	$8,100
Office Visit Copay:	$35
Preferred Generics:	$15
Preferred Brand Name:	$45^*
Non-Preferred Brand Name:	$95^*
Preferred Specialty:	$300^*
Non-Preferred Specialty:	$350^*

^*Subject to the deductible.

Benefit Details

Summary of Benefits and Coverage (SBC)
Medical Benefits
Prescription Drug Benefits

Directories

Pharmacy Directory
Provider Directory

Additional Information

Formulary
Member Handbook
Glossary of Health Coverage and Medical Terms
Wellness Resources
Pharmacy Resources
Value Added Services

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 Silver L 21 Select Plus

Benefit Details

Directories

Additional Information

Essential Benefits