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Community Ultra Select Gold 001 Off-Exchange

Community Health Choice
by Community Health Choice
2026 health insurance plan
Monthly Premium

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GoldHMO
Deductible · ind / family $0 / $0
Max out-of-pocket · ind / family $8,400 / $16,800
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Estimated yearly cost

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Coverage details

Deductible · individual $0 /yr
Deductible · family $0 /yr
Max out-of-pocket · individual $8,400 /yr
Max out-of-pocket · family $16,800 /yr
Includes child dental No
Includes adult dental No

Benefit details and out-of-pocket costs

Doctor visits

Preventive care & screenings No charge
Primary care visit $30 Copay
Specialist visit $65 Copay

Hospital & emergency

Emergency room $500 Copay
Inpatient facility $800 Copay per Day
Inpatient physician $0 Copay

Prescription drugs

Tier 1 · Generic $25 Copay
Tier 2 · Preferred brand $40 Copay
Tier 3 · Non-preferred brand $80 Copay
Tier 4 · Specialty 30.00% Coinsurance

Plan documents & tools

* Figures shown are only for in-network medical costs.

** Please check with the insurance company if copay and coinsurance rates are before or after the deductible.

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