Silver Elite Saver Plus - 91908OK0010030 Health Insurance Plan

Oscar Insurance Company health insurance plan with the Plan ID 91908OK0010030. The plan is called Silver Elite Saver Plus.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.64% (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 28.36% 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 91908OK0010030
Health Insurance Plan Year 2025
State Oklahoma
Health Insurance Issuer Oscar Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 91908OK0010030-00
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).

Providers Oklahoma All US States
All 6207 66655
PCP 367 897
Allergy 7 10
OB/GYN 10 22
Dentists N/A 2
Available Variants of the Health Plan

Standard Off Exchange Plan - 91908OK0010030-00

Standard On Exchange Plan - 91908OK0010030-01

Open to Indians below 300% FPL - 91908OK0010030-02

Open to Indians above 300% FPL - 91908OK0010030-03

73% AV Silver Plan - 91908OK0010030-04

87% AV Silver Plan - 91908OK0010030-05

94% AV Silver Plan - 91908OK0010030-06

Last Plan Update Date Thu, 17 Oct 2024 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of Silver Elite Saver Plus Health Insurance Plan, 91908OK0010030-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

50.00%

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

$100.00

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

$100.00

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

50.00%

50.00% Coinsurance after deductible
Dental Check-Up for Children
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

50.00%

50.00%
Emergency Transportation/Ambulance
YES

50.00%

50.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

50.00%

50.00% Coinsurance after deductible
Gender Affirming Care
NO
Generic Drugs
YES

Tier 1: $3.00

Tier 2: $30.00

100.00%
Habilitation Services

Limit: 25.0 Visit(s) per Benefit Period

YES

$100.00

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

Exclusions: We do not pay Home Health Care Benefits for Dietician services, except as specified for diabetes self- management training; Homemaker services; Maintenance therapy; Speech Therapy; Durable Medical Equipment; Food or home - delivered meals; Intravenous drug, fluid, or nutritional therapy, except when you have received Preauthorization from the Plan for these services.

YES

$100.00

50.00% Coinsurance after deductible
Hospice Services
YES

50.00%

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

50.00%

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)
YES

50.00%

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

50.00%

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

$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

Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism

YES

50.00%

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. 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

$60.00

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

$60.00

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$60.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

50.00%

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 30.0 Days per Benefit Period

YES

$100.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

50.00%

50.00% Coinsurance after deductible
Preferred Brand Drugs
YES

$125.00

100.00%
Prenatal and Postnatal Care
YES

0.00%

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

0.00%

0.00%
Primary Care Visit to Treat an Injury or Illness

Cost share applies to both in-person and telemedicine services. Virtual primary care services provided by Oscar-designated virtual care providers are covered in full. Virtual pediatric primary care services are not available through Oscar Medical Group; these services should be obtained in-person from in-network providers.

YES

$60.00

50.00% Coinsurance after deductible
Private-Duty Nursing

Limit: 85.0 Visit(s) per Benefit Period

Pre-authorization required.

YES

$100.00

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

50.00%

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

$100.00

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

$100.00

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

Exclusions: No Benefits are available: Once you can no longer improve from treatment; or for Custodial Care, or care for someone's convenience.

YES

50.00%

50.00% Coinsurance after deductible
Specialist Visit

Cost share applies to both in person and telemedicine services.

YES

$100.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.

YES

50.00%

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. 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

$60.00

50.00% Coinsurance after deductible
Transplant

Exclusions: Exclusions and Limitations Applicable to Organ/Tissue/Bone Marrow Transplants: The transplant must meet the criteria established by the Plan for assessing and performing organ or tissue transplants, or Bone Marrow Transplant procedures, as set forth in the Plan's written medical policies. In addition to the Exclusions set forth elsewhere in this Certificate, no Benefits will be provided for the following organ or tissue transplants or Bone Marrow Transplants or related services: Adrenal to brain transplants; Allogeneic islet cell transplants; High-Dose Chemotherapy or High-Dose Radiation Therapy if the associated autologous or allogeneic Bone Marrow Transplant, stem cell or progenitor cell treatment, or rescue is not a Covered Service; Small bowel transplants using a living donor; Any organ or tissue transplant or Bone Marrow Transplant from a non- human donor or for the use of non-human organs for extracorporeal support and/or maintenance; Any artificial device for transplantation/implantation, except in limited instances as reflected in the Plan's written medical policies; Any organ or tissue transplant or Bone Marrow Transplant procedure which the Plan considers to be Experimental, Investigational and/or Unproven in nature; Expenses related to the purchase, evaluation, Procurement Services or transplant procedure if the organ or tissue or bone marrow or stem cells or progenitor cells are sold rather than donated to the Subscriber recipient; All services, provided directly for or relative to any organ or tissue transplant, or Bone Marrow Transplant procedure which is not specifically listed as a Covered Service in this Certificate. The transplant must be performed in and by a Provider that meets the criteria established by the Plan for assessing and selecting Providers in the performance of organ or tissue transplants or Bone Marrow Transplant procedures.

YES

50.00%

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities

Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full.

YES

$50.00

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

$100.00

50.00% Coinsurance after deductible

Silver Elite Saver Plus Health Insurance Plan Variant 91908OK0010030-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.716374974601749
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 Silver 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 $400 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $200 per person
Drug EHB Deductible, In Network (Tier 1), Individual $200
Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 50.00%
Drug EHB Deductible, In Network (Tier 2), Family Per Group $400 per group
Drug EHB Deductible, In Network (Tier 2), Family Per Person $200 per person
Drug EHB Deductible, In Network (Tier 2), Individual $200
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 1.0
First Tier Utilization 44%
Formulary ID OKF001
Formulary URL URL
HIOS Product ID 91908OK001
Import Date 2024-10-17 01:02:25
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 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 $1000 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $500 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $500
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 Silver
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 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 91908OK0010030-00
Plan Marketing Name Silver Elite Saver Plus
Plan Type PPO
Plan Variant Marketing Name Silver Elite Saver Plus
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $5,000
SBC Scenario, Having a Baby, Copayment $400
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 $3,000
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $1,100
SBC Scenario, Treatment of a Simple Fracture, Copayment $600
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 OKS001
Source Name HIOS
Plan ID 91908OK0010030
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

Copay & Coinsurance of Silver Elite Saver Plus Health Insurance Plan, 91908OK0010030

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Silver Elite Saver Plus, 91908OK0010030 Health Insurance Plan, 91908OK0010030

  • Does Silver Elite Saver Plus Health Insurance Plan, 91908OK0010030 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (91908OK0010030) Health Insurance Plan, Variant (91908OK0010030-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy

    Does (91908OK0010030) Health Insurance Plan, Variant (91908OK0010030-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (91908OK0010030) Health Insurance Plan, Variant (91908OK0010030-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services Only

    Does (91908OK0010030) Health Insurance Plan, Variant (91908OK0010030-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy

    Does Silver Elite Saver Plus Health Insurance Plan, Variant (91908OK0010030-00) offer Disease Management Programs for Asthma?

    Yes, the Silver Elite Saver Plus Health Insurance Plan Variant 91908OK0010030-00 offers Disease Management Program for Asthma.

    Does Silver Elite Saver Plus Health Insurance Plan, Variant (91908OK0010030-00) offer Disease Management Programs for Heart disease?

    Yes, the Silver Elite Saver Plus Health Insurance Plan Variant 91908OK0010030-00 offers Disease Management Program for Heart disease.

    Does Silver Elite Saver Plus Health Insurance Plan, Variant (91908OK0010030-00) offer Disease Management Programs for Depression?

    Yes, the Silver Elite Saver Plus Health Insurance Plan Variant 91908OK0010030-00 offers Disease Management Program for Depression.

    Does Silver Elite Saver Plus Health Insurance Plan, Variant (91908OK0010030-00) offer Disease Management Programs for Diabetes?

    Yes, the Silver Elite Saver Plus Health Insurance Plan Variant 91908OK0010030-00 offers Disease Management Program for Diabetes.

    Does Silver Elite Saver Plus Health Insurance Plan, Variant (91908OK0010030-00) offer Disease Management Programs for Pregnancy?

    Yes, the Silver Elite Saver Plus Health Insurance Plan Variant 91908OK0010030-00 offers Disease Management Program 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