| Plan Premium | Medical Maximum out of pocket | Additional Benefits (these are benefits not covered by Medicare) | $0 You must continue to pay your Medicare Part B premium | $4,200 |
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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. For more details, see the Summary of Benefits or Evidence of Coverage below.
| 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 n the service |
| Inpatient Hospital | $265 per each day for days 1-7 |
This plan does not include Part D coverage for outpatient prescription drugs. Please note that you cannot have Silver Savings Silver Savings and another company’s Part D plan. If you do not have creditable coverage (as good as Medicare Part D), you may incur a penalty if you enroll in a Part D plan at a later date. Examples of creditable drug coverage are Indian Health Services or Veteran’s benefits.
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.