Coronavirus Self-Checker| Plan Premium | Medical Maximum out of pocket | Additional Benefits (these are benefits not covered by Medicare) | $30 You must continue to pay your Medicare Part B premium | $4,700 |
|---|
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 | $0 for Primary Care $35 for Specialist |
| Emergency & Urgent Care – Worldwide coverage | $90 for Emergency Room - waived if admitted $0 - $35 copay for Urgent Care |
| Outpatient Hospital | $250 copay |
| Outpatient Rehab (such as Physical Therapy) | $20 copay per visit |
| Outpatient Diagnostic Services | $0 - $100 copay, depending on the service |
| Inpatient Hospital | $245 copay per day for days 1-5 |
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 |
|---|---|
| Tier 1 - Preferred Generic | $5 copay |
| Tier 2 - Generic | $12 copay |
| Insulin Tier | $35 copay for covered insulin |
| Tier 3 - Preferred Brand Name | $40 copay - * $100 deductible applies |
| Tier 4 - non-Preferred Drugs | $95 copay - * $100 deductible applies |
| Tier 5 - Specialty Tier | 31% of the cost - * $100 deductible applies |
For 2022, this plan participates in the Part D Senior Savings Model which offers lower, stable and creditable out of pocket costs for covered insulin through the different Part D benefit coverage stages. You will pay a maximum of $35 for a 1-month supply of covered insulin during the Initial Coverage and Coverage Gap (or Donut Hole) stages of your benefit.
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 405-810-2012, TTY/TDD (800)722-0353, for more information on this plan or other options. We are available Monday through Friday from 8:00 to 6:00.
Coronavirus Self-Checker