| Plan Premium | Medical Maximum out of pocket | Additional Benefits (these are benefits not covered by Medicare) | $20 You must continue to pay your Medicare Part B premium | $3,900 |
|---|
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. 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 |
| Tier 3 - Preferred Brand Name | $40 copay |
| Insulin Tier | $35 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.