Saint Francis Silver Standardized

CommunityCare

Silver

Ind. deductible: $6,000
Family deductible: $6,000
Ind. OOP max: $8,900
Family OOP max: $8,900

Other cost-sharing reduction variants for this plan:

73% AV Level Silver Plan 87% AV Level Silver Plan 94% AV Level Silver Plan Limited Cost Sharing Plan Variation Standard Silver Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$472	—
30	$536	—
40	$603	—
50	$843	—
60	$1,281	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	0.00%
Primary Care Visit to Treat an Injury or Illness	$40.00

Specialist

Benefit	In-network
Specialist Visit	$40.00

Hospital

Benefit	In-network
Emergency Room Services	40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	40.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	$0.00
Urgent Care Centers or Facilities	$30.00

Pharmacy

Benefit	In-network
Generic Drugs	$20.00
Non-Preferred Brand Drugs	$80.00 Copay after deductible
Preferred Brand Drugs	$40.00
Specialty Drugs	$350.00 Copay after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	$0.00
Mental/Behavioral Health Outpatient Services	$40.00

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	30.00% 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	$80.00
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	25.00%
Dental Check-Up for Children	Not covered
Diabetes Education	No charge
Dialysis	$0.00
Durable Medical Equipment	$0.00
Emergency Transportation/Ambulance	40.00% Coinsurance after deductible
Eye Glasses for Children	40.00% Coinsurance after deductible
Habilitation Services	$40.00
Hearing Aids	30.00% Coinsurance after deductible
Home Health Care Services	40.00% Coinsurance after deductible
Hospice Services	$0.00
Imaging (CT/PET Scans, MRIs)	40.00% Coinsurance after deductible
Infertility Treatment	Not covered
Infusion Therapy	40.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	40.00% 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	30.00% Coinsurance after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	$40.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	25.00%
Outpatient Rehabilitation Services	$40.00
Prenatal and Postnatal Care	No charge
Private-Duty Nursing	30.00% 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	$40.00
Rehabilitative Speech Therapy	$40.00
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
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	40.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	$0.00
Transplant	$0.00
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 4 geographic areas.