Find Health Plans

University Community Care Plan by Community First – Silver Plan Standard

63251TX0020002
Silver
EPO

University Community Care Plan by Community First – Silver Plan Standard is a Silver EPO plan by Community First.

IMPORTANT: You are viewing the 2023 version of University Community Care Plan by Community First – Silver Plan Standard 63251TX0020002. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

University Community Care Plan by Community First – Silver Plan Standard is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of University Community Care Plan by Community First – Silver Plan Standard 63251TX0020002.
Insurer: Community First
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 63251TX0020002

Cost-Sharing Overview

University Community Care Plan by Community First – Silver Plan Standard offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for University Community Care Plan by Community First - Silver Plan Standard?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

University Community Care Plan by Community First – Silver Plan Standard offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what University Community Care Plan by Community First – Silver Plan Standard covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

University Community Care Plan by Community First – Silver Plan Standard includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 100.00%
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 100.00% Preauthorization may be required.
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00% Preauthorization may be required. Any procedure that could be deemed as cosmetic requires authorization.
Hospice Services
Covered
$80.00 100.00% Preauthorization may be required.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 100.00%
Home Health Care Services
Covered
$80.00 100.00%60 Visit(s) per Year Preauthorization is required.
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
$80.00 $80.00
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40.00% Coinsurance after deductible 100.00% Preauthorization is required. All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units.
Inpatient Physician and Surgical Services
Covered
$40.00 100.00% Preauthorization is required.
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 100.00%25 Visit(s) per Year Preauthorization is required.
Prenatal and Postnatal Care
Covered
$40.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 100.00% 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.
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00% Preauthorization may be required.
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00% Preauthorization is required.
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00% Preauthorization may be required. Certain services require preauthorization.
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00% Preauthorization is required.
Generic Drugs
Covered
$20.00 100.00%
Preferred Brand Drugs
Covered
$40.00 100.00%
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00%
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00% Prior authorization may apply to select specialty medications.
Outpatient Rehabilitation Services
Covered
$40.00 100.00%35 Visit(s) per Year Preauthorization is required. Limited to combined 35 visits per year, including Chiropractic.
Habilitation Services
Covered
$40.00 100.00%35 Visit(s) per Year Preauthorization is required. Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage.
Chiropractic Care
Covered
$80.00 100.00%35 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic.
Durable Medical Equipment
Covered
$80.00 100.00% Preauthorization is required.
Hearing Aids
Covered
$80.00 100.00% Preauthorization is required. To restore or correction of impaired speech or hearing loss.
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 100.00% Preauthorization is required for an MRI/MRA if not ordered by a Neurosurgeon or Orthopedic Surgeon. Preauthorization is required for an SPECT/3D imaging/CTA if not ordered by a cardiologist or cardiothoracic surgeon.
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$40.00 100.00%
Eye Glasses for Children
Covered
$40.00 100.00%
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 100.00% Preauthorization is required.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 100.00% Preauthorization is required.
Well Baby Visits and Care
Covered
$0.00 100.00%
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 100.00% Preauthorization is required for all Genetic testing.
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance after deductible 100.00% Preauthorization is required for Sleep Studies and Video EEG Monitoring.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
40.00% Coinsurance after deductible 100.00% Preauthorization is required.
Accidental Dental
Covered
40.00% Coinsurance after deductible 100.00%
Dialysis
Covered
$80.00 100.00%
Allergy Testing
Covered
$80.00 100.00% Preauthorization is required when not provided by an Allergist or Immunologist.
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00% Cancer Chemotherapy: requires preauthorization for any medication greater than $500 per dose.
Radiation
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$0.00 100.00%
Prosthetic Devices
Covered
$80.00 100.00% Preauthorization is required. Medically necessary foot orthotics are not subject to a calendar year maximum.
Infusion Therapy
Covered
$80.00 100.00% Preauthorization is required. Any injectable medication, including chemotherapy, greater than $500 per dose. Based on billed charges. NDC, HCPCS and billable units are required on the claim.
Treatment for Temporomandibular Joint Disorders
Covered
$80.00 100.00% Preauthorization is required. Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas.
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00% Preauthorization is required. Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following University Community Care Plan by Community First – Silver Plan Standard preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for University Community Care Plan by Community First – Silver Plan Standard including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for University Community Care Plan by Community First - Silver Plan Standard?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents