Silver Simple Diabetes - 91908OK0010045 Health Insurance Plan
Oscar Insurance Company health insurance plan with the Plan ID 91908OK0010045. The plan is called Silver Simple Diabetes.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.39% (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 29.61% 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 | 91908OK0010045 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | Oscar Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 91908OK0010045-00 | ||||||||||||||||||
| 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 - 91908OK0010045-00 Standard On Exchange Plan - 91908OK0010045-01 Open to Indians below 300% FPL - 91908OK0010045-02 Open to Indians above 300% FPL - 91908OK0010045-03 73% AV Silver Plan - 91908OK0010045-04 |
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| Last Plan Update Date | Sat, 16 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Silver Simple Diabetes Health Insurance Plan, 91908OK0010045-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
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 | $40.00 |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
|
YES | $40.00 |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance after deductible |
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% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 50.00% |
50.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Generic Drugs
|
YES | Tier 1: $0.00 Tier 2: $25.00 |
100.00% |
| Habilitation Services
Limit: 25.0 Visit(s) per Benefit Period |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hearing Aids
One hearing aid per ear every 48 months |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | $40.00 |
50.00% Coinsurance after deductible |
| Hospice Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% Coinsurance after deductible |
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% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
Labs (HbA1c screening, urinalysis, metabolic panel, lipid panel) to manage diabetes are covered in full. |
YES | Tier 1: $10.00 Tier 2: $65.00 |
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% Coinsurance after deductible |
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. |
YES | $0.00 |
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 | $0.00 |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Days per Benefit Period |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | $75.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 0.00% |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
50.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Limit: 85.0 Visit(s) per Benefit Period Pre-authorization required. |
YES | $40.00 |
50.00% Coinsurance after deductible |
| Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
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% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
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 |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
Diabetic eye exam and diabetic foot exams are covered in full. |
YES | $40.00 |
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% Coinsurance after deductible |
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. |
YES | $0.00 |
50.00% Coinsurance after deductible |
| Transplant
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $75.00 |
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 | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Silver Simple Diabetes Health Insurance Plan Variant 91908OK0010045-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7039267692969391 |
| 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 Silver Off Exchange Plan |
| 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 | 20% |
| Formulary ID | OKF001 |
| Formulary URL | URL |
| HIOS Product ID | 91908OK001 |
| 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 | 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 | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 91908OK0010045-00 |
| Plan Marketing Name | Silver Simple Diabetes |
| Plan Type | PPO |
| Plan Variant Marketing Name | Silver Simple Diabetes |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,800 |
| SBC Scenario, Having a Baby, Copayment | $200 |
| SBC Scenario, Having a Baby, Deductible | $6,500 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $80 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,600 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 80% |
| Service Area ID | OKS001 |
| Source Name | HIOS |
| Plan ID | 91908OK0010045 |
| 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 | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $13000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $13000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $6500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $6,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $38700 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $19350 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $19,350 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8550 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,550 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $17100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $8550 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $8,550 |
| 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 Simple Diabetes Health Insurance Plan, 91908OK0010045
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver Simple Diabetes, 91908OK0010045 Health Insurance Plan, 91908OK0010045
-
Does Silver Simple Diabetes Health Insurance Plan, 91908OK0010045 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (91908OK0010045) Health Insurance Plan, Variant (91908OK0010045-00) offer Disease Management Programs?
Does (91908OK0010045) Health Insurance Plan, Variant (91908OK0010045-00) have Out Of Country Coverage?
Does (91908OK0010045) Health Insurance Plan, Variant (91908OK0010045-00) have Out of Service Area Coverage?
Does (91908OK0010045) Health Insurance Plan, Variant (91908OK0010045-00) offer Disease Management Programs?
Does Silver Simple Diabetes Health Insurance Plan, Variant (91908OK0010045-00) offer Disease Management Programs for Asthma?
Does Silver Simple Diabetes Health Insurance Plan, Variant (91908OK0010045-00) offer Disease Management Programs for Heart disease?
Does Silver Simple Diabetes Health Insurance Plan, Variant (91908OK0010045-00) offer Disease Management Programs for Depression?
Does Silver Simple Diabetes Health Insurance Plan, Variant (91908OK0010045-00) offer Disease Management Programs for Diabetes?
Does Silver Simple Diabetes Health Insurance Plan, Variant (91908OK0010045-00) 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