| Plan Premium | Medical Maximum out of pocket | Additional Benefits (these are benefits not covered by Medicare) | $25 You must continue to pay your Medicare Part B premium | $4,500 |
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| Wallet Benefit |
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| Your wallet includes benefits for gym memberships, home & bathroom safety devices and more.Learn more about your wallet benefit here! |
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 ($0 for preventive screenings) $30 for Specialist |
| Emergency & Urgent Care – Worldwide coverage | $90 for Emergency Room - waived if admitted $30 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 | $240 copay each 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 | $0 copay |
| Tier 2 - Generic | $5 copay |
| Select Insulin Tier | $35 copay |
| Tier 3 - Preferred Brand Name | $40 copay |
| Tier 4 - Non-Preferred Drugs | $95 copay |
| Tier 5 - Specialty Tier | 33% of the cost |
You can save money by using your mail order benefit. You can purchase a 100 day supply of available drugs for a reduced cost. Mail order information.
You can call our Medicare team at (918) 594-5275, 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.