Community First

University Community Care Plan by Community First - Gold Plan

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $0.00 Family: not applicable Per Person: not applicable
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,500.00 Family: $15,000 Per Person: $7,500

Office Visit

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $65.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 30.00% Covered: Covered Benefit Explanation: Prior authorization may apply to select specialty medications.

Inpatient Coverage

Hospital Services	CoPay: $800.00 Copay per Day 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: $40.00 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: $40.00 CoInsurance: Not Applicable Covered: Covered

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: $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	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Routine Dental Checkups for Adults	Covered: Not Covered

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