University Community Care Plan by Community First - Gold Plan
Community First
Plan overview
Medical deductible
Individual: $0
Family: $0
Per Person: $0
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $7250
Family: $14500
Per Person: $7250
Office visit
Primary Doctor
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Specialist
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Non preferred brand drugs
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Generic drugs
CoPay: $10.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Specialty drugs
CoPay: Not Applicable
CoInsurance: 30.00%
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Prior authorization may apply to select specialty medications.
Inpatient coverage
Hospital services
CoPay: $800.00 Copay per Stay
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Preauthorization is required. All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units.
Inpatient services
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Preauthorization is required.
Emergency and urgent care
Emergency room
CoPay: $250.00
CoInsurance: Not Applicable
Covered: Covered
Urgent care facility
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: $800.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. Stays longer than the "global stay" requires preauthorization.
Pre and Postnatal office visit
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).