Friday Gold Copay - 91538OK0010018 Health Insurance Plan

Friday Health Insurance Company, Inc. health insurance plan with the Plan ID 91538OK0010018. The plan is called Friday Gold Copay.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.48% (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 21.52% 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 91538OK0010018
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 91538OK0010018-00
Provider Network(s) ['OKN001']
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 Oklahoma 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 - 91538OK0010018-00

Standard On Exchange Plan - 91538OK0010018-01

Open to Indians below 300% FPL - 91538OK0010018-02

Open to Indians above 300% FPL - 91538OK0010018-03

Last Plan Update Date Sat, 08 Oct 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Friday Gold Copay Health Insurance Plan, 91538OK0010018-00

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

20.00% 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

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Chiropractic Care

Prior authorization after 30 visits

YES

20.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

20.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

NO
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

20.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Only Durable Medical Equipment considered standard and/or basic as defined by nationally recognized guidelines are covered.

YES

20.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

45.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
YES

20.00% Coinsurance after deductible

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

$10.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Year

YES

$60.00

100.00%
Hearing Aids

One hearing aid per ear every 48 months.

YES

20.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 30.0 Visit(s) per Benefit Period

YES

20.00% Coinsurance after deductible

100.00%
Hospice Services
YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Limit: 25.0 Visit(s) per Benefit Period

Covered under Outpatient Therapy Services.

YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

20.00% 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.

YES

20.00% 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.

YES

$75.00

100.00%
Nutritional Counseling

Diabetes self-management training and training related to medical nutrition therapy.

YES

$60.00

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)
YES

No Charge, 20.00% Coinsurance after deductible

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

$60.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge, 20.00% 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

$40.00

100.00%
Prenatal and Postnatal Care
YES

$60.00

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

Pre-authorization required.

YES

20.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

20.00% Coinsurance after deductible

100.00%
Radiation
YES

20.00% 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

20.00% Coinsurance after deductible

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

$60.00

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

$60.00

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

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Benefit Period

YES

20.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs

Up to 30-day supply Retail only.

YES

$300.00

100.00%
Substance Abuse Disorder Inpatient Services

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

YES

20.00% 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

20.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$75.00

$75.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$100.00

100.00%

FRIDAY Gold Copay: Unlimited $0 Primary Care Visits, up to $10 Preferred Generic Rx, $0 Mental Health Counseling, Off-Exch. Health Insurance Plan Variant 91538OK0010018-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.78482622
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 Gold Off Exchange Plan
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 OKF010
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 Gold
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) 91538OK0010018-00
Plan Marketing Name Friday Gold Copay
Plan Type HMO
Plan Variant Marketing Name FRIDAY Gold Copay: Unlimited $0 Primary Care Visits, up to $10 Preferred Generic Rx, $0 Mental Health Counseling, Off-Exch.
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,000
SBC Scenario, Having a Baby, Copayment $200
SBC Scenario, Having a Baby, Deductible $2,300
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,200
SBC Scenario, Having Diabetes, Deductible $1,600
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OKS001
Source Name HIOS
Plan ID 91538OK0010018
State Code OK
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $16500 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $8250 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $8,250
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $4600 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $2300 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $2,300
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $4600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2300 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,300
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 $16500 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8250 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,250
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 Yes

Copay & Coinsurance of Friday Gold Copay Health Insurance Plan, 91538OK0010018

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

Frequently Asked Questions(FAQ) about Friday Gold Copay, 91538OK0010018 Health Insurance Plan, 91538OK0010018

  • Does Friday Gold Copay Health Insurance Plan, 91538OK0010018 support Mail Ordering?

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

  • Does (91538OK0010018) Health Insurance Plan, Variant (91538OK0010018-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Diabetes

    Does (91538OK0010018) Health Insurance Plan, Variant (91538OK0010018-00) have Out Of Country Coverage?

    Yes. Details: Urgent and Emergent only

    Does (91538OK0010018) Health Insurance Plan, Variant (91538OK0010018-00) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergent only

    Does (91538OK0010018) Health Insurance Plan, Variant (91538OK0010018-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Diabetes

    Does FRIDAY Gold Copay: Unlimited $0 Primary Care Visits, up to $10 Preferred Generic Rx, $0 Mental Health Counseling, Off-Exch. Health Insurance Plan, Variant (91538OK0010018-00) offer Disease Management Programs for Diabetes?

    Yes, the FRIDAY Gold Copay: Unlimited $0 Primary Care Visits, up to $10 Preferred Generic Rx, $0 Mental Health Counseling, Off-Exch. Health Insurance Plan Variant 91538OK0010018-00 offers Disease Management Program for Diabetes.

 

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