Bronze Elite- Deductible+PCP Saver Plus (Select) - 11574IL0020005 Health Insurance Plan

Oscar Health Plan, Inc. health insurance plan with the Plan ID 11574IL0020005. The plan is called Bronze Elite- Deductible+PCP Saver Plus (Select).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.94% (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 35.06% 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 11574IL0020005
Health Insurance Plan Year 2023
State Illinois
Health Insurance Issuer Oscar Health Plan, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 11574IL0020005-00
Provider Network(s) ['ILN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Illinois All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 11574IL0020005-00

Standard On Exchange Plan - 11574IL0020005-01

Open to Indians below 300% FPL - 11574IL0020005-02

Open to Indians above 300% FPL - 11574IL0020005-03

Last Plan Update Date Wed, 22 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Bronze Elite- Deductible+PCP Saver Plus (Select) Health Insurance Plan, 11574IL0020005-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

$1,200.00

100.00%
Accidental Dental
YES

$350.00

100.00%
Acupuncture
NO
Allergy Testing
YES

$125.00

100.00%
Bariatric Surgery
YES

$3,000.00

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

50.00%

100.00%
Chiropractic Care

Limit: 25.0 Visit(s) per Benefit Period

YES

$125.00

100.00%
Cosmetic Surgery

Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.

YES

$3,000.00

100.00%
Delivery and All Inpatient Services for Maternity Care

The per day copayment will apply for a maximum of 2 days.

YES

$3,000.00

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management.

YES

$0.00

100.00%
Dialysis
YES

50.00%

100.00%
Durable Medical Equipment
YES

50.00%

100.00%
Emergency Room Services
YES

$1,500.00

$1,500.00
Emergency Transportation/Ambulance
YES

$1,500.00

$1,500.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

50.00%

100.00%
Gender Affirming Care
YES

$3,000.00

100.00%
Generic Drugs

Oscar is on a mission to make your prescriptions more affordable. That?s why your savings start on day 1 of your new plan. All Oscar members have access to 24/7 virtual urgent care services. Depending on your plan, if your Oscar Virtual Urgent Care provider prescribes any prescriptions on the Generics: Tier 1a or Generics: Tier 1b list during your visit, those prescriptions will be free.* Generics: Tier 1a: Drugs on this list will never cost you more than $3, no matter who prescribes them. Check to see if your prescriptions are on the $3 Prescription List at https://www.hioscar.com/prescriptions/3-dollar-list Prescriptions included in Generics: Tier 1b will always cost you less than $30, no matter who prescribes them?even if you haven?t hit your deductible. Find out which Tiers the drugs you take are on at www.hioscar.com/search *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan. Virtual visits with other providers in Oscar?s network will not be free and the additional savings will not apply.

YES

Tier 1: $3.00

Tier 2: $30.00

100.00%
Habilitation Services

Treatment must be medically necessary and therapeutic and not investigational.

YES

$125.00

100.00%
Hearing Aids

Limit: 2.0 Visit(s) per 3 Years

Benefits are for bone anchored hearing aids. Quantity limit applies to hearing aids for children.

YES

50.00%

100.00%
Home Health Care Services
YES

$125.00

100.00%
Hospice Services
YES

50.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$750.00

100.00%
Infertility Treatment

Limitations vary based on procedures.

YES

50.00%

100.00%
Infusion Therapy
YES

50.00%

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

The per day copayment will apply for a maximum of 2 days.

YES

$3000.00 Copay per Day after deductible

100.00%
Inpatient Physician and Surgical Services
YES

$350.00

100.00%
Laboratory Outpatient and Professional Services

Benefit provided for outpatient services and when these services are related to surgery or medical care.

YES

Tier 1: $25.00

Tier 2: $50.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child

Limitations vary based on procedures.

NO
Mental/Behavioral Health Inpatient Services

The per day copayment will apply for a maximum of 2 days.

YES

$3000.00 Copay per Day after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$125.00

100.00%
Non-Preferred Brand Drugs
YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

$40.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Limitations vary based on procedures.

NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$40.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$1,200.00

100.00%
Outpatient Rehabilitation Services

Maintenance therapies not covered.

YES

$125.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$350.00

100.00%
Preferred Brand Drugs
YES

$50.00 Copay after deductible

100.00%
Prenatal and Postnatal Care
YES

$0.00

100.00%
Preventive Care/Screening/Immunization
YES

$0.00

100.00%
Primary Care Visit to Treat an Injury or Illness

Virtual visits with an Oscar Care urgent care provider are unlimited and always $0?even if you haven?t hit your deductible. Depending on your plan, many prescriptions and labs will also cost you $0, if they?re ordered by your Oscar Virtual Urgent Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan.

YES

$40.00

100.00%
Private-Duty Nursing
YES

$125.00

100.00%
Prosthetic Devices
YES

50.00%

100.00%
Radiation
YES

50.00%

100.00%
Reconstructive Surgery

Only includes benefits for mastectomy-related services.

YES

$3,000.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Maintenance Speech Therapy is not covered.

YES

$125.00

100.00%
Rehabilitative Speech Therapy

When rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome) attention disorder, conceptual handicap or mental retardation, except as may be provided under this Certificate for Autism Spectrum Disorder(s).

YES

$125.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

YES

$0.00

100.00%
Routine Foot Care

Only covered for persons diagnosed with diabetes.

YES

$0.00

100.00%
Skilled Nursing Facility

The per day copayment will apply for a maximum of 2 days.

YES

$3000.00 Copay per Day after deductible

100.00%
Specialist Visit
YES

$125.00

100.00%
Specialty Drugs
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

The per day copayment will apply for a maximum of 2 days.

YES

$3000.00 Copay per Day after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$125.00

100.00%
Transplant
YES

$3,000.00

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50.00%

100.00%
Urgent Care Centers or Facilities
YES

$75.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00

100.00%
X-rays and Diagnostic Imaging

Benefit provided for outpatient services and when these services are related to surgery or medical care.

YES

$125.00

100.00%

Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 11574IL0020005-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.649355635
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze 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 $13000 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $6500 per person
Drug EHB Deductible, In Network (Tier 1), Individual $6,500
Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 50.00%
Drug EHB Deductible, In Network (Tier 2), Family Per Group $13000 per group
Drug EHB Deductible, In Network (Tier 2), Family Per Person $6500 per person
Drug EHB Deductible, In Network (Tier 2), Individual $6,500
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, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 0.998104
First Tier Utilization 20%
Formulary ID ILF001
Formulary URL URL
HIOS Product ID 11574IL002
Import Date 2/22/2023 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 2
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer ID 11574
Issuer Marketplace Marketing Name Oscar Health Plan, Inc.
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 per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
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 per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Expanded Bronze
Multiple In Network Tiers Yes
National Network No
Network ID ILN002
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 11574IL0020005-00
Plan Marketing Name Bronze Elite- Deductible+PCP Saver Plus (Select)
Plan Type HMO
Plan Variant Marketing Name Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $4,100
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 $600
SBC Scenario, Having Diabetes, Deductible $4,200
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $100
SBC Scenario, Treatment of a Simple Fracture, Copayment $2,100
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 80%
Service Area ID ILS002
Source Name SERFF
Specialist Requiring a Referral All Specialist Providers
Plan ID 11574IL0020005
State Code IL
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 Bronze Elite- Deductible+PCP Saver Plus (Select) Health Insurance Plan, 11574IL0020005

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

Frequently Asked Questions(FAQ) about Bronze Elite- Deductible+PCP Saver Plus (Select), 11574IL0020005 Health Insurance Plan, 11574IL0020005

  • Does Bronze Elite- Deductible+PCP Saver Plus (Select) Health Insurance Plan, 11574IL0020005 support Mail Ordering?

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

  • Does (11574IL0020005) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (11574IL0020005) Health Insurance Plan, Variant (11574IL0020005-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (11574IL0020005) Health Insurance Plan, Variant (11574IL0020005-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services only

    Does (11574IL0020005) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Asthma?

    Yes, the Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 11574IL0020005-00 offers Disease Management Program for Asthma.

    Does Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Heart disease?

    Yes, the Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 11574IL0020005-00 offers Disease Management Program for Heart disease.

    Does Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Depression?

    Yes, the Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 11574IL0020005-00 offers Disease Management Program for Depression.

    Does Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Diabetes?

    Yes, the Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 11574IL0020005-00 offers Disease Management Program for Diabetes.

    Does Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 11574IL0020005-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Low back pain?

    Yes, the Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 11574IL0020005-00 offers Disease Management Program for Low back pain.

    Does Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Pregnancy?

    Yes, the Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 11574IL0020005-00 offers Disease Management Program for Pregnancy.

    Does Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (11574IL0020005-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Bronze Elite- Deductible+PCP Saver Plus (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 11574IL0020005-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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