| Plan Premium | Additional Benefits (these are benefits not covered by Medicare) | $0 You must continue to pay your Medicare Part B premium |
|---|
| Wallet Benefit |
|---|
| Your wallet includes benefits for gym memberships, hearing aids, home & bathroom safety 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
| In-Network | Out-of-Network | |
|---|---|---|
| Primay Care | $0 for Primary Care | 30% |
| Specialist | $40 for Specialist | 30% |
| Urgent Care | $40 for Urgent Care | $40 for Urgent Care |
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 | 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% copay |
You can save money by using your mail order benefit. You can purchase a 100 day supply of available drugs for a reduced cost.
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.