Oscar Insurance Company health insurance plan with the Plan ID 91908OK0010005. The plan is called Bronze Elite- Deductible+PCP Saver Plus.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.94% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.06% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
Health Insurance Plan ID | 91908OK0010005 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Oklahoma | ||||||||||||||||||
Health Insurance Issuer | Oscar Insurance Company | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 91908OK0010005-01 | ||||||||||||||||||
Provider Network(s) | ['OKN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 91908OK0010005-00 Standard On Exchange Plan - 91908OK0010005-01 |
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Last Plan Update Date | Fri, 24 Feb 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | $350.00 |
50.00% Coinsurance after deductible |
Acupuncture
|
NO | ||
Allergy Testing
Issuer clarifies this is a covered benefit but stipulated under the Medical Policy and not written in the member materials. |
YES | $125.00 |
50.00% Coinsurance after deductible |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | 50.00% |
50.00% Coinsurance after deductible |
Chiropractic Care
|
YES | $125.00 |
50.00% Coinsurance after deductible |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
The per day copayment will apply for a maximum of 2 days. |
YES | $3,000.00 |
50.00% Coinsurance after deductible |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
NO | ||
Diabetes Education
|
YES | $0.00 |
50.00% Coinsurance after deductible |
Dialysis
|
YES | 50.00% |
50.00% Coinsurance after deductible |
Durable Medical Equipment
|
YES | 50.00% |
50.00% Coinsurance after deductible |
Emergency Room Services
|
YES | $1,500.00 |
$1,500.00 |
Emergency Transportation/Ambulance
|
YES | $1,500.00 |
$1,500.00 |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 50.00% |
50.00% Coinsurance after deductible |
Gender Affirming Care
|
YES | $3,000.00 |
50.00% Coinsurance after deductible |
Generic Drugs
Oscar is on a mission to make your prescriptions more affordable. That?s why your savings start on day 1 of your new plan. All Oscar members have access to 24/7 virtual urgent care services. Depending on your plan, if your Oscar Virtual Urgent Care provider prescribes any prescriptions on the Generics: Tier 1a or Generics: Tier 1b list during your visit, those prescriptions will be free.* Generics: Tier 1a: Drugs on this list will never cost you more than $3, no matter who prescribes them. Check to see if your prescriptions are on the $3 Prescription List at https://www.hioscar.com/prescriptions/3-dollar-list Prescriptions included in Generics: Tier 1b will always cost you less than $30, no matter who prescribes them?even if you haven?t hit your deductible. Find out which Tiers the drugs you take are on at www.hioscar.com/search *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan. Virtual visits with other providers in Oscar?s network will not be free and the additional savings will not apply. |
YES | Tier 1: $3.00 Tier 2: $30.00 |
100.00% |
Habilitation Services
Limit: 25.0 Visit(s) per Benefit Period |
YES | $125.00 |
50.00% Coinsurance after deductible |
Hearing Aids
One hearing aid per ear every 48 months. |
YES | 50.00% |
50.00% Coinsurance after deductible |
Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | $125.00 |
50.00% Coinsurance after deductible |
Hospice Services
|
YES | 50.00% |
50.00% Coinsurance after deductible |
Imaging (CT/PET Scans, MRIs)
|
YES | $750.00 |
50.00% Coinsurance after deductible |
Infertility Treatment
|
NO | ||
Infusion Therapy
Limit: 25.0 Visit(s) per Benefit Period Covered under Outpatient Therapy Services. |
YES | 50.00% |
50.00% Coinsurance after deductible |
Inpatient Hospital Services (e.g., Hospital Stay)
The per day copayment will apply for a maximum of 2 days. |
YES | $3000.00 Copay per Day |
50.00% Coinsurance after deductible |
Inpatient Physician and Surgical Services
|
YES | $350.00 |
50.00% Coinsurance after deductible |
Laboratory Outpatient and Professional Services
|
YES | Tier 1: $25.00 Tier 2: $50.00 |
50.00% Coinsurance after deductible |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
The per day copayment will apply for a maximum of 2 days. Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. |
YES | $3,000.00 |
50.00% Coinsurance after deductible |
Mental/Behavioral Health Outpatient Services
Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. |
YES | $125.00 |
50.00% Coinsurance after deductible |
Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
Diabetes self-management training and training related to medical nutrition therapy. |
YES | $40.00 |
50.00% Coinsurance after deductible |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
50.00% Coinsurance after deductible |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $1,200.00 |
50.00% Coinsurance after deductible |
Outpatient Rehabilitation Services
Limit: 30.0 Days per Benefit Period |
YES | $125.00 |
50.00% Coinsurance after deductible |
Outpatient Surgery Physician/Surgical Services
|
YES | $350.00 |
50.00% Coinsurance after deductible |
Preferred Brand Drugs
|
YES | $50.00 Copay after deductible |
100.00% |
Prenatal and Postnatal Care
|
YES | $0.00 |
50.00% Coinsurance after deductible |
Preventive Care/Screening/Immunization
|
YES | $0.00 |
50.00% Coinsurance after deductible |
Primary Care Visit to Treat an Injury or Illness
Virtual visits with an Oscar Care urgent care provider are unlimited and always $0?even if you haven?t hit your deductible. Depending on your plan, many prescriptions and labs will also cost you $0, if they?re ordered by your Oscar Virtual Urgent Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan. |
YES | $40.00 |
50.00% Coinsurance after deductible |
Private-Duty Nursing
Limit: 85.0 Visit(s) per Benefit Period Pre-authorization required. |
YES | $125.00 |
50.00% Coinsurance after deductible |
Prosthetic Devices
|
YES | 50.00% |
50.00% Coinsurance after deductible |
Radiation
|
YES | 50.00% |
50.00% Coinsurance after deductible |
Reconstructive Surgery
Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary. |
YES | $3,000.00 |
50.00% Coinsurance after deductible |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 25.0 Visit(s) per Benefit Period Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined). |
YES | $125.00 |
50.00% Coinsurance after deductible |
Rehabilitative Speech Therapy
Limit: 25.0 Visit(s) per Benefit Period Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined). |
YES | $125.00 |
50.00% Coinsurance after deductible |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00 |
50.00% Coinsurance after deductible |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period The per day copayment will apply for a maximum of 2 days. |
YES | $3000.00 Copay per Day |
50.00% Coinsurance after deductible |
Specialist Visit
|
YES | $125.00 |
50.00% Coinsurance after deductible |
Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
The per day copayment will apply for a maximum of 2 days. Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. |
YES | $3,000.00 |
50.00% Coinsurance after deductible |
Substance Abuse Disorder Outpatient Services
Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. |
YES | $125.00 |
50.00% Coinsurance after deductible |
Transplant
|
YES | $3,000.00 |
50.00% Coinsurance after deductible |
Treatment for Temporomandibular Joint Disorders
|
NO | ||
Urgent Care Centers or Facilities
|
YES | $75.00 |
50.00% Coinsurance after deductible |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | $0.00 |
50.00% Coinsurance after deductible |
X-rays and Diagnostic Imaging
|
YES | $125.00 |
50.00% Coinsurance after deductible |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.649355635 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Bronze On Exchange Plan |
Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
Drug EHB Deductible, In Network (Tier 1), Family Per Group | $13000 per group |
Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6500 per person |
Drug EHB Deductible, In Network (Tier 1), Individual | $6,500 |
Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
Drug EHB Deductible, In Network (Tier 2), Family Per Group | $13000 per group |
Drug EHB Deductible, In Network (Tier 2), Family Per Person | $6500 per person |
Drug EHB Deductible, In Network (Tier 2), Individual | $6,500 |
Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
Drug EHB Deductible, Out of Network, Individual | Not Applicable |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 20% |
Formulary ID | OKF001 |
Formulary URL | URL |
HIOS Product ID | 91908OK001 |
Import Date | 2/24/2023 1:01 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 2 |
HSA Eligible | No |
New/Existing Plan | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer ID | 91908 |
Issuer Marketplace Marketing Name | Oscar Insurance Company |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | No |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
Medical EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
Medical EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
Medical EHB Deductible, In Network (Tier 2), Individual | $0 |
Medical EHB Deductible, Out of Network, Family Per Group | $1000 per group |
Medical EHB Deductible, Out of Network, Family Per Person | $500 per person |
Medical EHB Deductible, Out of Network, Individual | $500 |
Metal Level | Expanded Bronze |
Multiple In Network Tiers | Yes |
National Network | No |
Network ID | OKN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emergency Services only. |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergency and Urgent Services only. |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 91908OK0010005-01 |
Plan Marketing Name | Bronze Elite- Deductible+PCP Saver Plus |
Plan Type | PPO |
Plan Variant Marketing Name | Bronze Elite- Deductible+PCP Saver Plus ($0 Virtual Urgent Care Visits with Select Providers) |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $4,100 |
SBC Scenario, Having a Baby, Deductible | $0 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $600 |
SBC Scenario, Having Diabetes, Deductible | $4,200 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $2,100 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Second Tier Utilization | 80% |
Service Area ID | OKS001 |
Source Name | HIOS |
Plan ID | 91908OK0010005 |
State Code | OK |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18200 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9100 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18200 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9100 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,100 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
Unique Plan Design | No |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API