Community Premier Gold 005 (No deductible for PCP, Specialist, Urgent Care & Generics, $0 PCP 24/7 Virtual Care Options)

Community Health Choice

Gold

Ind. deductible: $2,500
Family deductible: $2,500
Ind. OOP max: $7,500
Family OOP max: $7,500

Other cost-sharing reduction variants for this plan:

Limited Cost Sharing Plan Variation Standard Gold Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$463	—
30	$525	—
40	$592	—
50	$827	—
60	$1,256	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	$20.00

Specialist

Benefit	In-network
Specialist Visit	$0.00

Hospital

Benefit	In-network
Emergency Room Services	25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	0.00%
Outpatient Surgery Physician/Surgical Services	0.00%
Urgent Care Centers or Facilities	$0.00

Pharmacy

Benefit	In-network
Generic Drugs	$0.00
Non-Preferred Brand Drugs	$0.00
Preferred Brand Drugs	$50.00 Copay after deductible
Specialty Drugs	0.00%

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	0.00%
Mental/Behavioral Health Outpatient Services	$20.00

Other

Benefit	In-network
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	Not covered
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	$40.00
Acupuncture	Not covered
Allergy Testing	$40.00 Copay after deductible
Bariatric Surgery	Not covered
Chemotherapy	$0.00
Chiropractic Care	$40.00 Copay after deductible
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	25.00% Coinsurance after deductible
Dental Check-Up for Children	Not covered
Diabetes Education	$20.00 Copay after deductible
Dialysis	$40.00 Copay after deductible
Durable Medical Equipment	0.00%
Emergency Transportation/Ambulance	$0.00
Eye Glasses for Children	$40.00 Copay after deductible
Habilitation Services	$40.00 Copay after deductible
Hearing Aids	0.00%
Home Health Care Services	$40.00 Copay after deductible
Hospice Services	$40.00 Copay after deductible
Imaging (CT/PET Scans, MRIs)	25.00% Coinsurance after deductible
Infertility Treatment	Not covered
Infusion Therapy	$40.00 Copay after deductible
Inpatient Physician and Surgical Services	No Charge after deductible
Laboratory Outpatient and Professional Services	$20.00 Copay after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	Not covered
Nutritional Counseling	Not covered
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	$0.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	0.00%
Outpatient Rehabilitation Services	$40.00 Copay after deductible
Prenatal and Postnatal Care	$40.00 Copay after deductible
Private-Duty Nursing	Not covered
Prosthetic Devices	30.00% Coinsurance after deductible
Radiation	$40.00 Copay after deductible
Reconstructive Surgery	25.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	$40.00 Copay after deductible
Rehabilitative Speech Therapy	$40.00 Copay after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	$40.00 Copay after deductible
Routine Foot Care	Not covered
Skilled Nursing Facility	25.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	0.00%
Substance Abuse Disorder Outpatient Services	$0.00
Transplant	25.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	$40.00
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	$0.00

Plan rules

Service area

This plan covers 20 geographic areas.