Friday Silver HSA - 91538OK0010014 Health Insurance Plan
Friday Health Insurance Company, Inc. health insurance plan with the Plan ID 91538OK0010014. The plan is called Friday Silver HSA.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 91538OK0010014 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | Friday Health Insurance Company, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 91538OK0010014-02 | ||||||||||||||||||
| Provider Network(s) | ['OKN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 91538OK0010014-00 Standard On Exchange Plan - 91538OK0010014-01 Open to Indians below 300% FPL - 91538OK0010014-02 Open to Indians above 300% FPL - 91538OK0010014-03 73% AV Silver Plan - 91538OK0010014-04 |
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| Last Plan Update Date | Sat, 08 Oct 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Friday Silver HSA Health Insurance Plan, 91538OK0010014-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $0.00, 0.00% |
100.00% |
| Chiropractic Care
Prior authorization after 30 visits |
YES | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
NO | ||
| Diabetes Education
|
YES | $0.00, 0.00% |
100.00% |
| Dialysis
|
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
Only Durable Medical Equipment considered standard and/or basic as defined by nationally recognized guidelines are covered. |
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
|
YES | $0.00, 0.00% |
100.00% |
| Generic Drugs
Up to 30-day supply Retail and up to 90-day supply Retail & Mail Order, except narcotics and Specialty Drugs. |
YES | $0.00, 0.00% |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Hearing Aids
One hearing aid per ear every 48 months. |
YES | $0.00, 0.00% |
100.00% |
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | $0.00, 0.00% |
100.00% |
| Hospice Services
|
YES | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $0.00, 0.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Limit: 25.0 Visit(s) per Benefit Period Covered under Outpatient Therapy Services. |
YES | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $0.00, 0.00% |
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. |
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. |
YES | $0.00, 0.00% |
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. |
YES | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
Diabetes self-management training and training related to medical nutrition therapy. |
YES | $0.00, 0.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Maximum of 30 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined). |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00, 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
Limit: 85.0 Visit(s) per Benefit Period Pre-authorization required. |
YES | $0.00, 0.00% |
100.00% |
| Prosthetic Devices
|
YES | $0.00, 0.00% |
100.00% |
| Radiation
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Maximum of 30 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined). |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Maximum of 30 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined). |
YES | $0.00, 0.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period |
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
|
YES | $0.00, 0.00% |
100.00% |
| Specialty Drugs
Up to 30-day supply Retail only. |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. |
YES | $0.00, 0.00% |
100.00% |
| Transplant
|
YES | $0.00, 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
100.00% |
FRIDAY Silver AI/AN Zero: Unlimited $0 Primary Care Visits, $0 Preferred Generic Rx, $0 Mental Health Counseling Health Insurance Plan Variant 91538OK0010014-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1 |
| 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 | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Diabetes |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | OKF005 |
| Formulary URL | URL |
| HIOS Product ID | 91538OK001 |
| Import Date | 10/8/2022 1:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 91538 |
| Issuer Marketplace Marketing Name | Friday Health Plans |
| 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 | Yes |
| Out of Country Coverage Description | Urgent and Emergent only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Urgent and Emergent only |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 91538OK0010014-02 |
| Plan Marketing Name | Friday Silver HSA |
| Plan Type | HMO |
| Plan Variant Marketing Name | FRIDAY Silver AI/AN Zero: Unlimited $0 Primary Care Visits, $0 Preferred Generic Rx, $0 Mental Health Counseling |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| 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 | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS001 |
| Source Name | HIOS |
| Plan ID | 91538OK0010014 |
| State Code | OK |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Friday Silver HSA Health Insurance Plan, 91538OK0010014
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Friday Silver HSA, 91538OK0010014 Health Insurance Plan, 91538OK0010014
-
Does Friday Silver HSA Health Insurance Plan, 91538OK0010014 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (91538OK0010014) Health Insurance Plan, Variant (91538OK0010014-02) offer Disease Management Programs?
Does (91538OK0010014) Health Insurance Plan, Variant (91538OK0010014-02) have Out Of Country Coverage?
Does (91538OK0010014) Health Insurance Plan, Variant (91538OK0010014-02) have Out of Service Area Coverage?
Does (91538OK0010014) Health Insurance Plan, Variant (91538OK0010014-02) offer Disease Management Programs?
Does FRIDAY Silver AI/AN Zero: Unlimited $0 Primary Care Visits, $0 Preferred Generic Rx, $0 Mental Health Counseling Health Insurance Plan, Variant (91538OK0010014-02) offer Disease Management Programs for Diabetes?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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