TARO Direct Primary Care Silver 1900 ($0 DPC + $0 PCP + $0 Mental Health) - 58944OK0010003 Health Insurance Plan
Taro Health Plan of Oklahoma, Inc. health insurance plan with the Plan ID 58944OK0010003. The plan is called TARO Direct Primary Care Silver 1900 ($0 DPC + $0 PCP + $0 Mental Health).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.94% (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 28.06% 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 | 58944OK0010003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | Taro Health Plan of Oklahoma, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 58944OK0010003-01 | ||||||||||||||||||
| 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 - 58944OK0010003-00 Standard On Exchange Plan - 58944OK0010003-01 Open to Indians below 300% FPL - 58944OK0010003-02 Open to Indians above 300% FPL - 58944OK0010003-03 73% AV Silver Plan - 58944OK0010003-04 |
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| Last Plan Update Date | Tue, 22 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of TARO Direct Primary Care Silver 1900 ($0 DPC + $0 PCP + $0 Mental Health) Health Insurance Plan, 58944OK0010003-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| 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 | $75.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period Chiropractic Care limit is combined with Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
YES | $50.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Prior authorization may be required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Services are only covered if medically necessary |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Up to 30-day supply Retail and up to 90-day supply Retail & Mail Order, except narcotics and Specialty Drugs. Insulin will not exceed $30 for a 30-day supply and $90 for a 90-day supply. |
YES | $25.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
YES | $50.00 |
100.00% |
| Hearing Aids
One hearing aid per ear every 48 months |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Prior authorization required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Prior authorization may be required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
We may cover Standard Fertility Preservation Services, for individuals diagnosed with cancer and who are within Reproductive Age, when a medically necessary treatment may directly or indirectly cause Iatrogenic Infertility. |
NO | ||
| Infusion Therapy
Limit: 25.0 Visit(s) per Benefit Period Covered under Outpatient Therapy Services. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior authorization may be required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Prior authorization may be required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 50.00% 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
Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. Prior authorization required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. |
YES | No Charge |
100.00% |
| Non-Preferred Brand Drugs
Up to 30-day supply Retail and up to 90-day supply Retail & Mail Order, except narcotics and Specialty Drugs. Insulin will not exceed $30 for a 30-day supply and $90 for a 90-day supply. |
YES | $100.00 |
100.00% |
| Nutritional Counseling
Diabetes self-management training and training related to medical nutrition therapy. |
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Prior authorization may be required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Days per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
YES | $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Prior authorization may be required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Up to 30-day supply Retail and up to 90-day supply Retail & Mail Order, except narcotics and Specialty Drugs. Insulin will not exceed $30 for a 30-day supply and $90 for a 90-day supply. |
YES | $70.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $75.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge |
100.00% |
| Private-Duty Nursing
Limit: 85.0 Visit(s) per Benefit Period Prior authorization required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Prior authorization may be required |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% 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 | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year One eye exam every 12 months from last date of service. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period Prior authorization required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $75.00 |
100.00% |
| Specialty Drugs
Up to 30-day supply Retail only. |
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. Prior authorization required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. |
YES | No Charge |
100.00% |
| Transplant
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $100.00 |
$100.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 50.00% Coinsurance after deductible |
100.00% |
TARO Direct Primary Care Silver 1900 ($0 DPC + $0 PCP + $0 Mental Health) Health Insurance Plan Variant 58944OK0010003-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7194227939754191 |
| 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 On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | OKF002 |
| Formulary URL | URL |
| HIOS Product ID | 58944OK001 |
| Import Date | 2024-10-22 01:01:28 |
| 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 | 58944 |
| Issuer Marketplace Marketing Name | Taro Health Plan |
| 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 |
| Out of Service Area Coverage Description | Emergency Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 58944OK0010003-01 |
| Plan Marketing Name | TARO Direct Primary Care Silver 1900 ($0 DPC + $0 PCP + $0 Mental Health) |
| Plan Type | HMO |
| Plan Variant Marketing Name | TARO Direct Primary Care Silver 1900 ($0 DPC + $0 PCP + $0 Mental Health) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $5,300 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,900 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $90 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS001 |
| Source Name | HIOS |
| Plan ID | 58944OK0010003 |
| State Code | OK |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $9,200 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $3800 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $1900 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $1,900 |
| 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 | $3800 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1900 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,900 |
| 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 | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| 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 TARO Direct Primary Care Silver 1900 ($0 DPC + $0 PCP + $0 Mental Health) Health Insurance Plan, 58944OK0010003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about TARO Direct Primary Care Silver 1900 ($0 DPC + $0 PCP + $0 Mental Health), 58944OK0010003 Health Insurance Plan, 58944OK0010003
-
Does TARO Direct Primary Care Silver 1900 ($0 DPC + $0 PCP + $0 Mental Health) Health Insurance Plan, 58944OK0010003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (58944OK0010003) Health Insurance Plan, Variant (58944OK0010003-01) have Out Of Country Coverage?
Does (58944OK0010003) Health Insurance Plan, Variant (58944OK0010003-01) have Out of Service Area Coverage?
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