2024 EOBs are now available online. Please contact Customer Service for EOBs prior to the current year.

Plan Details

CommunityCare Gold IH221

98905OK0130043-00
Plan Year:
2024

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:$1,100
Individual Out of Pocket Maximum:$8,700
Office Visit Copay:$30
Preferred Generics:$15
Preferred Brand Name:$45
Non-Preferred Brand Name:$95*
Individual Rx Deductible:Integrated
Preferred Specialty:$300*
Non-Preferred Specialty:$350*
Specialist Copay:$55
Coinsurance:40%*
First 3 telehealth visits at $0.
*Subject to the deductible.

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