Ascenson St. John Empower Gold $0 PCP
CommunityCare · 2027 plan year
Gold
- Ind. deductible
- $2,000
- Family deductible
- $4,000
- Ind. OOP max
- $8,900
- Family OOP max
- $17,800
Compare with other Gold plans in OK
Side by side: deductibles, out-of-pocket limits and copays.
Other cost-sharing reduction variants for this plan:
More CommunityCare plans in OK
Monthly premiums by age
The same in all 2 areas this plan covers.
| Age | Individual | Individual + tobacco |
|---|---|---|
| Under 15 | $407 | $407 |
| 21 | $532 | $638 |
| 30 | $603 | $724 |
| 40 | $679 | $815 |
| 50 | $949 | $1,139 |
| 60 | $1,443 | $1,731 |
| 64 and over | $1,595 | $1,914 |
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 | No charge |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $75.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | 38.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | 38.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services | 40.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities | $50.00 |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $15.00 |
| Non-Preferred Brand Drugs | 50.00% Coinsurance after deductible |
| Preferred Brand Drugs | $75.00 |
| Specialty Drugs | 60.00% Coinsurance after deductible |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Inpatient Services | 38.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services | No charge |
Other
| Benefit | In-network |
|---|---|
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 40.00% Coinsurance after deductible |
| Acupuncture | Not covered |
| Allergy Testing | 40.00% Coinsurance after deductible |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Chemotherapy | 40.00% Coinsurance after deductible |
| Chiropractic Care | $75.00 |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 38.00% Coinsurance after deductible |
| Dental Check-Up for Children | Not covered |
| Diabetes Education | No charge |
| Dialysis | 40.00% Coinsurance after deductible |
| Durable Medical Equipment | 40.00% |
| Emergency Transportation/Ambulance | $50.00 Copay after deductible |
| Eye Glasses for Children | 40.00% Coinsurance after deductible |
| Habilitation Services | No charge |
| Hearing Aids | 40.00% |
| Home Health Care Services | 40.00% Coinsurance after deductible |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | 38.00% Coinsurance after deductible |
| Infertility Treatment | Not covered |
| Infusion Therapy | 40.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 38.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 40.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | 40.00% Coinsurance after deductible |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | No charge |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 40.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | No charge |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | 40.00% Coinsurance after deductible |
| Prosthetic Devices | 40.00% Coinsurance after deductible |
| Radiation | 40.00% Coinsurance after deductible |
| Reconstructive Surgery | 40.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | No charge |
| Rehabilitative Speech Therapy | No charge |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | No charge |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | Not covered |
| Skilled Nursing Facility | 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 38.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | No charge |
| Transplant | 40.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | Not covered |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 40.00% Coinsurance after deductible |
Plan rules
Service area
This plan covers 5 geographic areas.
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