Bronze Elite + PCP Saver Plus (Select) - 11574IL0020005 Health Insurance Plan
Oscar Health Plan, Inc. health insurance plan with the Plan ID 11574IL0020005. The plan is called Bronze Elite + PCP Saver Plus (Select).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.76% (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 35.24% 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 | 11574IL0020005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | Oscar Health Plan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 11574IL0020005-00 | ||||||||||||||||||
| 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 - 11574IL0020005-00 Standard On Exchange Plan - 11574IL0020005-01 |
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| Last Plan Update Date | Mon, 18 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Bronze Elite + PCP Saver Plus (Select) Health Insurance Plan, 11574IL0020005-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | $0.00 |
100.00% |
| Accidental Dental
|
YES | $350.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $125.00 |
100.00% |
| Bariatric Surgery
|
YES | $3,000.00 |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 25.0 Visit(s) per Benefit Period |
YES | $125.00 |
100.00% |
| Cosmetic Surgery
Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered. |
YES | $3,000.00 |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
The per day copayment will apply for a maximum of 2 days. |
YES | $3,000.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management. |
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 Benefit Period |
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
YES | $3,000.00 |
100.00% |
| Generic Drugs
|
YES | Tier 1: $3.00 Tier 2: $30.00 |
100.00% |
| Habilitation Services
Treatment must be medically necessary and therapeutic and not investigational. |
YES | $125.00 |
100.00% |
| Hearing Aids
Limit: 2.0 Visit(s) per 3 Years Benefits are for bone anchored hearing aids. Quantity limit applies to hearing aids for children. |
YES | 50.00% |
100.00% |
| Home Health Care Services
Benefits will be provided for services under a Coordinated Home Care Program. |
YES | $125.00 |
100.00% |
| Hospice Services
|
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Benefit provided for outpatient services and when these services are related to surgery or medical. |
YES | $750.00 |
100.00% |
| Infertility Treatment
Limitations vary based on procedures. |
YES | $1,200.00 |
100.00% |
| Infusion Therapy
|
YES | 50.00% |
100.00% |
| 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 |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $350.00 |
100.00% |
| Laboratory Outpatient and Professional Services
Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | Tier 1: $25.00 Tier 2: $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
The per day copayment will apply for a maximum of 2 days. |
YES | $3000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
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
|
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
|
YES | $40.00 |
100.00% |
| Private-Duty Nursing
|
YES | $125.00 |
100.00% |
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Only includes benefits for mastectomy-related services. |
YES | $3,000.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Maintenance Speech Therapy is not covered. |
YES | $125.00 |
100.00% |
| Rehabilitative Speech Therapy
When rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome) attention disorder, conceptual handicap or mental retardation, except as may be provided under this Certificate for Autism Spectrum Disorder(s). |
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 Benefit Period |
YES | $0.00 |
100.00% |
| Routine Foot Care
Only covered for persons diagnosed with diabetes. |
YES | $125.00 |
100.00% |
| Skilled Nursing Facility
The per day copayment will apply for a maximum of 2 days. |
YES | $3000.00 Copay per Day |
100.00% |
| Specialist Visit
|
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 2 days. |
YES | $3000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $125.00 |
100.00% |
| Transplant
|
YES | $3,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $75.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | $125.00 |
100.00% |
Bronze Elite + PCP Saver Plus (Select) Health Insurance Plan Variant 11574IL0020005-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.6475888182581899 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| 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 | 0.998 |
| First Tier Utilization | 20% |
| Formulary ID | ILF001 |
| Formulary URL | URL |
| HIOS Product ID | 11574IL002 |
| Import Date | 2023-12-18 20:02:01 |
| 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 | 11574 |
| Issuer Marketplace Marketing Name | Oscar Health Plan, Inc. |
| 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 | ILN002 |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 11574IL0020005-00 |
| Plan Marketing Name | Bronze Elite + PCP Saver Plus (Select) |
| Plan Type | HMO |
| Plan Variant Marketing Name | Bronze Elite + PCP Saver Plus (Select) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $4,000 |
| 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 | $200 |
| 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 | ILS002 |
| Source Name | SERFF |
| Plan ID | 11574IL0020005 |
| State Code | IL |
| 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 | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,450 |
| 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 (Select) Health Insurance Plan, 11574IL0020005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze Elite + PCP Saver Plus (Select), 11574IL0020005 Health Insurance Plan, 11574IL0020005
-
Does Bronze Elite + PCP Saver Plus (Select) Health Insurance Plan, 11574IL0020005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (11574IL0020005) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs?
Does (11574IL0020005) Health Insurance Plan, Variant (11574IL0020005-00) have Out Of Country Coverage?
Does (11574IL0020005) Health Insurance Plan, Variant (11574IL0020005-00) have Out of Service Area Coverage?
Does (11574IL0020005) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs?
Does Bronze Elite + PCP Saver Plus (Select) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Asthma?
Does Bronze Elite + PCP Saver Plus (Select) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Heart disease?
Does Bronze Elite + PCP Saver Plus (Select) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Depression?
Does Bronze Elite + PCP Saver Plus (Select) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Diabetes?
Does Bronze Elite + PCP Saver Plus (Select) Health Insurance Plan, Variant (11574IL0020005-00) 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