Our Plans and Rates

Community Health Choice Plan Overview 2017

  Copay Plans Deductible Plans**
MEMBER COST SHARE COMMUNITY HEALTH CHOICE HMO GOLD 001 COMMUNITY HEALTH CHOICE HMO SILVER 002 COMMUNITY HEALTH CHOICE HMO BRONZE 003 COMMUNITY HEALTH CHOICE HMO SILVER 004* COMMUNITY HEALTH CHOICE HMO GOLD 005
  Plan ID
27248TX0010001
Plan ID
27248TX0010002
Plan ID
27248TX0010003
Plan ID
27248TX0010004
Plan ID
27248TX0010005
Medical Deductible (Individual/family) $0 $0 $5,000/$10,000 $1,500/$3,000 $500/$1,000
Out-Of-Pocket Max (Individual/family) $5,000/$10,000 $7,150/$14,300 $7,150/$14,300 $7,150/$14,300 $5,000/$10,000
Coinsurance 0% 0% 0% 0% 0%
PCP Office Visit $30 $40 $40 $30 $20
Specialist Office Visit $65 $75 $65 $50 $45
Medical Imaging(CT/PET Scans, MRIs $300 $600 $500 $500 $400
PRESCRIPTION DRUGS
Generic $15 $35 $10 (after $200 deductible) $10 $10
Preferred Brand $40 $100 $85 (after $200 deductible) $50 $40
Non-Preferred Brand $80 $110 $110 (after $200 deductible) $100 $70
Specialty High Cost Drugs 30% 50%

40% (after $200 deductible

45% 30%
 

**For deductible plans, copays apply only after deductible has been met
♦ For Bronze deductible plan, 3 PCP office visits are covered at the PCP copay prior to deductible.
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KelseyCare powered by Community Health Choice Plan Overview 2017

  Copay Plans
MEMBER COST SHARE KELSEYCARE POWERED BY COMMUNITY HEALTH CHOICE HMO GOLD 006 KELSEYCARE POWERED BY COMMUNITY HEALTH CHOICE HMO GOLD 007*
  Plan ID
27248TX0010006
Plan ID
27248TX0010007
Medical Deductible (Individual/family) $0 $0
Out-Of-Pocket (Individual/family) $5,000/$10,000 $7,150/$14,300
Coinsurance 0% 0%
PCP Office Visit $30 $40
Specialist Office Visit $65 $75
Medical Imaging(CT/PET Scans, MRIs) $300 $600
PRESCRIPTION DRUGS
Generic $15 $35
Preferred Brand $40 $100
Non-Preferred Brand $80 $110
Specialty High Cost Drugs 30% 50%
 

*Your costs may be even less if you quality for financial help.
Download printable version.