MyBlue Gold HMO℠ Standard - 87571OK0510063 Health Insurance Plan
Blue Cross Blue Shield of Oklahoma health insurance plan with the Plan ID 87571OK0510063. The plan is called MyBlue Gold HMO℠ Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (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 21.94% 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 | 87571OK0510063 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of Oklahoma | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 87571OK0510063-00 | ||||||||||||||||||
| Provider Network(s) | MYBLUE-HMO | ||||||||||||||||||
| 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 - 87571OK0510063-00 Standard On Exchange Plan - 87571OK0510063-01 |
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| Last Plan Update Date | Tue, 22 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of MyBlue Gold HMO℠ Standard Health Insurance Plan, 87571OK0510063-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
When services are provided in an office setting, cost shares may vary. Please see benefit booklet for details. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
Except when medically necessary. |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period All frames will first apply towards the allowance. Discount will apply on remaining balance, after the allowance. See benefit book for details |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. Certain generic drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details. |
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
YES | $30.00 |
100.00% |
| Hearing Aids
1 hearing aid per ear (2 hearing aids) every 48 months for any covered member. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $100.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Member cost share may increase when using a setting other than office. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Member cost share may increase when using a setting other than office. |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Covered when medically necessary |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $60.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care. |
YES | $30.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
Limit: 85.0 Visit(s) per Benefit Period |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| 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 | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period When purchasing Out of Network, reimbursements are available. See benefit book for details |
YES | No Charge |
100.00% |
| Routine Foot Care
Covered when medically necessary |
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. Certain specialty drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Member cost share may increase when using a setting other than office. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Member cost share may increase when using a setting other than office. |
YES | $30.00 |
100.00% |
| Transplant
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $45.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | 25.00% Coinsurance after deductible |
100.00% |
MyBlue Gold HMO℠ Standard Health Insurance Plan Variant 87571OK0510063-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7806125763529309 |
| 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 Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | OKF005 |
| Formulary URL | URL |
| HIOS Product ID | 87571OK051 |
| Import Date | 2024-10-22 01:01:28 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 87571 |
| Issuer Marketplace Marketing Name | Blue Cross and Blue Shield of Oklahoma |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | OKN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage outside our service area is available for Emergency and Urgent Care services only. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 87571OK0510063-00 |
| Plan Marketing Name | MyBlue Gold HMO℠ Standard |
| Plan Type | HMO |
| Plan Variant Marketing Name | MyBlue Gold HMO℠ Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $40 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS032 |
| Source Name | HIOS |
| Specialist Requiring a Referral | Referrals are required for some services. Please check with your Medical Group for details. |
| Plan ID | 87571OK0510063 |
| 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 | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 MyBlue Gold HMO℠ Standard Health Insurance Plan, 87571OK0510063
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about MyBlue Gold HMO℠ Standard, 87571OK0510063 Health Insurance Plan, 87571OK0510063
-
Does MyBlue Gold HMO℠ Standard Health Insurance Plan, 87571OK0510063 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (87571OK0510063) Health Insurance Plan, Variant (87571OK0510063-00) offer Disease Management Programs?
Does (87571OK0510063) Health Insurance Plan, Variant (87571OK0510063-00) have Out Of Country Coverage?
Does (87571OK0510063) Health Insurance Plan, Variant (87571OK0510063-00) have Out of Service Area Coverage?
Does (87571OK0510063) Health Insurance Plan, Variant (87571OK0510063-00) offer Disease Management Programs?
Does MyBlue Gold HMO℠ Standard Health Insurance Plan, Variant (87571OK0510063-00) offer Disease Management Programs for Asthma?
Does MyBlue Gold HMO℠ Standard Health Insurance Plan, Variant (87571OK0510063-00) offer Disease Management Programs for Heart disease?
Does MyBlue Gold HMO℠ Standard Health Insurance Plan, Variant (87571OK0510063-00) offer Disease Management Programs for Depression?
Does MyBlue Gold HMO℠ Standard Health Insurance Plan, Variant (87571OK0510063-00) offer Disease Management Programs for Diabetes?
Does MyBlue Gold HMO℠ Standard Health Insurance Plan, Variant (87571OK0510063-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does MyBlue Gold HMO℠ Standard Health Insurance Plan, Variant (87571OK0510063-00) offer Disease Management Programs for Low back pain?
Does MyBlue Gold HMO℠ Standard Health Insurance Plan, Variant (87571OK0510063-00) 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