Plan Details

CommunityCare PPO Platinum C19 Standard

87698OK0110027-00

Plan Year:

2023

Platinum Metal plans cover an estimated 90% of your medical and prescription drug costs. They also limit your annual out-of-pocket expenses. Platinum Plans are the most expensive of all the "metal plans."

Individual Deductible:	$1,000
Individual Out of Pocket Maximum:	$3,000
Office Visit Copay:	$20
Out of Network Coinsurance:	40%*
Preferred Generics:	$10
Preferred Brand Name:	$40
Non-Preferred Brand Name:	$70
Individual Rx Deductible:	None
Preferred Specialty:	$160
Non-Preferred Specialty:	$210
OON Individual Deductible:	$2,000
OON Family Deductible:	$6,000
OON OOP Individual Deductible:	Unlimited
OON OOP Family Deductible:	Unlimited
OON Office Visit Copay:	40%*
Specialist Copay:	$50
OON Specialist Copay:	40%*
Coinsurance:	10%*

^*Subject to the deductible.

Insure Oklahoma Qualified

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