Community First

University Community Care Plan by Community First - Silver Plan Standard

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $5,000.00 Family: $10000 Per Person: $5000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,000.00 Family: $16000 Per Person: $8000

Office Visit

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $80.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: $350.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Prior authorization may apply to select specialty medications.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible 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: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Preauthorization is required.

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible 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
Pre and Postnatal Office Visit	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered