| Plan Premium | Additional Benefits (these are benefits not covered by Medicare) | $0 You must continue to pay your Medicare Part B premium |
|---|
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 | |
|---|---|---|
| Doctors Visits | $0 for Primary Care $40 for Specialist | 30% of the cost |
| Emergency & Urgent Care - Worldwide Coverage | $90 for Emergency Room $40 for Urgent Care | $90 for Emergency Room $40 for Urgent Care |
| Outpatient Hospital | $260 | 30% of the cost |
| Outpatient Rehab (such as Physical Therapy) | $20 | 30% of the cost |
| Outpatient Diagnostic Services (lab, X-ray, MRI) | $0-$125, depending on the service | 30% of the cost |
| Inpatient Hospital | $245 each day for days 1-6 | 30% of the cost |
This plan includes Part D (outpatient prescription drug coverage) - your copay will depend on what Tier level your prescription is. Check our formulary to see what tier your drug is in. Copays can change if you move out of the Initial Coverage level. Your copays may also be different if you have Extra Help or if you also have Medicaid.
| Outpatient Prescription Drug Copays* | 30-day Supply |
|---|---|
| Tier 1 - Preferred Generic | $0 copay |
| Tier 2 - Generic | $5 copay |
| 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 |
* These are your copays while you are in the Initial Coverage Stage of your Part D coverage. For more information, see the Pharmacy and Prescription Info page.
Save time and money by ordering an extended day supply (up to 100 days) of your drugs with our convenient mail order program.
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.
Members on a Medicare Retiree group plan may have different benefits. Check your plan year benefit grid or call Customer Service with questions. Be sure to let us know what retiree group you are with.