Plan Premium | Medical Maximum out of pocket | Additional Benefits (these are benefits not covered by Medicare) | $0 You must continue to pay your Medicare Part B premium | $6,100 |
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Common Medical benefits and your copays - remember that if you reach your Medical Maximum Out of Pocket limit, the rest of your Medicare-covered medical services are paid by CommunityCare
Doctors Visits provider search | $5 for Primary Care $40 for Specialist |
Emergency & Urgent Care – Worldwide coverage | $90 for Emergency Room - waived if admitted $40 for Urgent Care |
Outpatient Hospital | $325 copay |
Outpatient Rehab (such as Physical Therapy) | $40 copay per visit |
Outpatient Diagnostic Services | 20% of the cost |
Inpatient Hospital | $300 copay each day for days 1-7 |
This plan includes Part D (outpatient prescription drug coverage) - your copay will depend on what Tier level your prescription is. Copays can change if you move out of the Initial Coverage level.
Initial Coverage Level Copays formulary search | 30-day Supply |
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Tier 1 - Preferred Generic | $5 copay - * $0 copay for an extended day supply |
Tier 2 - Generic | $13 copay - * $0 copay for an extended day supply |
Tier 3 - Preferred Brand Name | $40 copay |
Tier 4 - non-Preferred Drugs | $95 copay |
Tier 5 - Specialty Tier | 33% of the cost |
We also have mail order through CVS or Walgreens where you can purchase a 90-day supply of available drugs for a reduced cost. Mail order information.
You can call our Medicare team at 918-594-5275 for more information on this plan or other options. We are available Monday through Friday from 8:00 to 6:00.