Bronze Elite + PCP Saver Plus - 57424NE0010005 Health Insurance Plan
Oscar Insurance Company health insurance plan with the Plan ID 57424NE0010005. The plan is called Bronze Elite + PCP Saver Plus.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.63% (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 35.37% 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 | 57424NE0010005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Nebraska | ||||||||||||||||||
| Health Insurance Issuer | Oscar Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 57424NE0010005-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 57424NE0010005-00 Standard On Exchange Plan - 57424NE0010005-01 |
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| Last Plan Update Date | Thu, 10 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Bronze Elite + PCP Saver Plus Health Insurance Plan, 57424NE0010005-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Exclusions: Benefits are limited to treatment provided within 12 months of the injury. Benefits are not available for orthodontics or dental implants. Benefits shall not be provided for such Services when the Injury occurs as the result of eating, biting or chewing. |
YES | 50.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $125.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Chiropractic physiotherapy has a combined limit with PT, OT and speech therapies of 45 sessions per calendar year. Chiropractic manipulative adjustments have a combined limit with osteopathic physiotherapy of 20 sessions per calendar year |
YES | $125.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
The per day copayment will apply for a maximum of two (2) days. |
YES | $3,000.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00 |
100.00% |
| Dialysis
|
YES | 50.00% |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% |
100.00% |
| Emergency Room Services
|
YES | $2,000.00 |
$2,000.00 |
| Emergency Transportation/Ambulance
|
YES | $2,000.00 |
$2,000.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | Tier 1: $3.00 Tier 2: $30.00 |
100.00% |
| Habilitation Services
Limit: 45.0 Treatment(s) per Year Exclusions: Autism exclusions: Services for treatment of autism spectrum disorders, including but not limited to applied behavioral analysis and early intensive behavioral intervention. Services for autism spectrum disorders or pervasive developmental conditions, developmental delays or sensory integration disorders unless otherwise required by law or specifically covered elsewhere in this Contract. Health care Services that help a person keep, learn, or improve skills and functioning for daily living. These Services may include physical and occupational therapy, speech language pathology and other Services for people with disabilities in a variety of Inpatient and/or Outpatient settings. Quantitative limits on services apply to outpatient, only. |
YES | $125.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Days per Year |
YES | $125.00 |
100.00% |
| Hospice Services
The Covered Person must have a life expectancy of six months or less as documented in writing by the attending Physician. The Hospice Services must be ordered by a Physician. Services provided must be appropriate for palliative support or management of a Covered Person with terminal medical Illness. |
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $750.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
The per day copayment will apply for a maximum of two (2) days. |
YES | $3,000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $350.00 |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $50.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: Excludes programs that treat obesity or gambling addiction and residential treatment programs. Exclusions include: programs for co-dependency; employee assistance; probation; prevention; educational or self-help; programs which treat obesity, gambling, or nicotine addiction; Custodial Care for Mental Illness and/or Substance Dependence and Abuse; halfway house or Substance Dependence and Abuse maintenance programs; programs ordered by the Court determined to be not Medically Necessary. The per day copayment will apply for a maximum of two (2) days. |
YES | $3,000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $125.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | $40.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $1,200.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 45.0 Treatment(s) per Year Limits apply to rehabilitation and habilitation combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year) |
YES | $125.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $350.00 |
100.00% |
| Preferred Brand Drugs
|
YES | $100.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cost share applies to both in-person and telemedicine services. |
YES | $40.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Available only post-mastectomy or when required to restore, reconstruct or correct any bodily function that was lost, impaired or damaged as a result of Injury or Illness. |
YES | $3,000.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 45.0 Visit(s) per Year Limits apply to rehabilitation and habilitation combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year) |
YES | $125.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 45.0 Visit(s) per Year Limits apply to rehabilitation and habilitation combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year) |
YES | $125.00 |
100.00% |
| 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 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year Exclusions: Skilled nursing facility care does not include: a) supportive Services for a stabilized condition; b) care which can be learned and given by unlicensed or uncertified medical personnel; c) routine health care Services; d) general maintenance or supervision of routine daily activities; or e) routine administration of oral or nonprescription drugs The per day copayment will apply for a maximum of two (2) days. |
YES | $3,000.00 Copay per Day |
100.00% |
| Specialist Visit
Cost share applies to both in-person and telemedicine services. |
YES | $125.00 |
100.00% |
| 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 two (2) days. |
YES | $3,000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $125.00 |
100.00% |
| Transplant
|
YES | $3,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | $1,200.00 |
100.00% |
| Urgent Care Centers or Facilities
Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full. |
YES | $75.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $125.00 |
100.00% |
Bronze Elite + PCP Saver Plus Health Insurance Plan Variant 57424NE0010005-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.646347333903356 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze Off 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, Pregnancy |
| EHB Percent of Total Premium | 0.9999 |
| First Tier Utilization | 44% |
| Formulary ID | NEF001 |
| Formulary URL | URL |
| HIOS Product ID | 57424NE001 |
| Import Date | 2024-10-10 20:01:47 |
| 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 | 57424 |
| 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 | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | NEN001 |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 57424NE0010005-00 |
| Plan Marketing Name | Bronze Elite + PCP Saver Plus |
| Plan Type | EPO |
| Plan Variant Marketing Name | Bronze Elite + PCP Saver Plus |
| 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 | 56% |
| Service Area ID | NES001 |
| Source Name | SERFF |
| Plan ID | 57424NE0010005 |
| State Code | NE |
| 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 | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,200 |
| 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 |
Copay & Coinsurance of Bronze Elite + PCP Saver Plus Health Insurance Plan, 57424NE0010005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze Elite + PCP Saver Plus, 57424NE0010005 Health Insurance Plan, 57424NE0010005
-
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, 57424NE0010005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (57424NE0010005) Health Insurance Plan, Variant (57424NE0010005-00) offer Disease Management Programs?
Does (57424NE0010005) Health Insurance Plan, Variant (57424NE0010005-00) have Out Of Country Coverage?
Does (57424NE0010005) Health Insurance Plan, Variant (57424NE0010005-00) have Out of Service Area Coverage?
Does (57424NE0010005) Health Insurance Plan, Variant (57424NE0010005-00) offer Disease Management Programs?
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, Variant (57424NE0010005-00) offer Disease Management Programs for Asthma?
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, Variant (57424NE0010005-00) offer Disease Management Programs for Heart disease?
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, Variant (57424NE0010005-00) offer Disease Management Programs for Depression?
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, Variant (57424NE0010005-00) offer Disease Management Programs for Diabetes?
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, Variant (57424NE0010005-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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