Clear Silver + Vision + Adult Dental - 62505OK0130015 Health Insurance Plan
Celtic Insurance Company health insurance plan with the Plan ID 62505OK0130015. The plan is called Clear Silver + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 87.65% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 12.35% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.65% (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 12.35% 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 | 62505OK0130015 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 62505OK0130015-05 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 62505OK0130015-00 Standard On Exchange Plan - 62505OK0130015-01 Open to Indians below 300% FPL - 62505OK0130015-02 Open to Indians above 300% FPL - 62505OK0130015-03 73% AV Silver Plan - 62505OK0130015-04 |
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| Last Plan Update Date | Sat, 16 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Clear Silver + Vision + Adult Dental Health Insurance Plan, 62505OK0130015-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
50.00% |
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Chiropractic Care
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Dialysis
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year OON: Up to $50 for frames, $37.50 for lenses and $91 for contacts in lieu of eyeglasses. See EOC for lens limits. |
YES | No Charge |
No Charge |
| Gender Affirming Care
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Generic Drugs
Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 25.0 Visit(s) per Year Per year, limited to 25 visits combined (occupational, speech and physical therapy). Inpatient habilitation services limited to 30 days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Hearing Aids
Limit: 2.0 Item(s) per Benefit Period One hearing aid per ear every 4 years. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Home Health Care Services
Limit: 30.0 Visit(s) per Year |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Hospice Services
Exclusions: Excludes respite care. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Infertility Treatment
Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
NO | ||
| Infusion Therapy
Limit: 25.0 Visit(s) per Year |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit. |
NO | ||
| Major Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
50.00% |
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Other Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Mental/Behavioral Health Urgent Care
|
YES | No Charge after deductible |
30.00% |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 25.0 Visit(s) per Year Per year, limited to 25 visits combined (occupational, speech and physical therapy). Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
30.00% |
| Primary Care Visit to Treat an Injury or Illness
Unlimited Virtual 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Private-Duty Nursing
Limit: 85.0 Visit(s) per Year |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Prosthetic Devices
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Radiation
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Reconstructive Surgery
1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality... 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 25.0 Visit(s) per Year Maximum of 25 outpatient visits for physical therapy, occupational therapy and speech therapy (combined). Inpatient rehabilitation limited to 30 days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 25.0 Visit(s) per Year Maximum of 25 outpatient visits for physical therapy, occupational therapy and speech therapy (combined). Inpatient rehabilitation limited to 30 days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | No Charge |
No Charge |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year OON exam: Up to $38.50. Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eyeglasses. OON eyewear benefit: covered up to $50 for frames, lenses up to $37.50 and contact lenses up to $91. |
YES | No Charge |
No Charge |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Up to $38.50 OON |
YES | No Charge |
No Charge |
| Routine Foot Care
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Skilled Nursing Facility
Limit: 30.0 Days per Year |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Specialist Visit
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Substance Use Disorder Emergency Room
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Outpatient Other Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Substance Use Disorder Urgent Care
|
YES | No Charge after deductible |
30.00% |
| Tier 3 Generic Drugs
Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
30.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
30.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 62505OK0130015-05 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.876527707026328 |
| 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 | 87% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9615 |
| First Tier Utilization | 100% |
| Formulary ID | OKF002 |
| Formulary URL | URL |
| HIOS Product ID | 62505OK013 |
| Import Date | 2023-12-16 01:02:09 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 87.65% |
| Issuer ID | 62505 |
| Issuer Marketplace Marketing Name | Ambetter of Oklahoma |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | OKN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 62505OK0130015-05 |
| Plan Marketing Name | Clear Silver + Vision + Adult Dental |
| Plan Type | PPO |
| Plan Variant Marketing Name | Clear Silver + Vision + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $1,600 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $1,600 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,600 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS001 |
| Source Name | HIOS |
| Plan ID | 62505OK0130015 |
| 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 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $12200 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $6100 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $6,100 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1600 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,600 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $9000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $4500 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $4,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $3200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,600 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Clear Silver + Vision + Adult Dental Health Insurance Plan, 62505OK0130015
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Clear Silver + Vision + Adult Dental, 62505OK0130015 Health Insurance Plan, 62505OK0130015
-
Does Clear Silver + Vision + Adult Dental Health Insurance Plan, 62505OK0130015 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (62505OK0130015) Health Insurance Plan, Variant (62505OK0130015-05) offer Disease Management Programs?
Does (62505OK0130015) Health Insurance Plan, Variant (62505OK0130015-05) have Out Of Country Coverage?
Does (62505OK0130015) Health Insurance Plan, Variant (62505OK0130015-05) have Out of Service Area Coverage?
Does (62505OK0130015) Health Insurance Plan, Variant (62505OK0130015-05) offer Disease Management Programs?
Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (62505OK0130015-05) offer Disease Management Programs for Asthma?
Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (62505OK0130015-05) offer Disease Management Programs for Heart disease?
Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (62505OK0130015-05) offer Disease Management Programs for Diabetes?
Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (62505OK0130015-05) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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