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Plan Details

98905OK0130041-00

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:	$4,000
Individual Out of Pocket Maximum:	$8,300
Office Visit Copay:	$30
Preferred Generics:	$10
Preferred Brand Name:	$45
Non-Preferred Brand Name:	$95^*
Individual Rx Deductible:	Integrated
Preferred Specialty:	$300^*
Non-Preferred Specialty:	$350^*
Specialist Copay:	$55
Coinsurance:	20%^*

First 3 telehealth visits at $0.

^*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 Gold L21 Select Plus

Benefit Details

Directories

Additional Information

Essential Benefits