| Field | Data |
|---|---|
| Health Insurance Plan ID | 91908OK0010033 |
| Health Insurance Plan Year | 2022 |
| State | Oklahoma |
| Health Insurance Issuer | Oscar Insurance Company |
| Last Plan Update Date | Wed, 26 Oct 2022 00:00 GMT |
| Last Import Date | Tue, 21 Mar 2023 13:10 GMT |
| Health Insurance Plan Variant | 91908OK0010033-00 |
| Available Variants of the Health Plan | |
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.763199162 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| 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 | 1 |
| First Tier Utilization | 20% |
| Formulary ID | OKF001 |
| Formulary URL | URL |
| HIOS Product ID | 91908OK001 |
| Import Date | 8/18/2021 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 | 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 | Gold |
| 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 | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 91908OK0010033-00 |
| Plan Marketing Name | Gold Simple |
| Plan Type | PPO |
| Plan Variant Marketing Name | Gold Simple ($3 Drugs + $0 Virtual Care) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,200 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,900 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 80% |
| Service Area ID | OKS001 |
| Source Name | HIOS |
| Plan ID | 91908OK0010033 |
| 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 | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $2000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $2,000 |
| TEHBDedOutOfNetFamilyPerGroup | $16000 per group |
| TEHBDedOutOfNetFamilyPerPerson | $8000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $8,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6550 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,550 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $13100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $6550 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $6,550 |
| 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 |
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|---|---|---|---|---|---|
| Non preferred brand | 1 month in retail | $0 | After deductible | 50.0% | After deductible | YES |
| Non preferred brand | 3 month in mail | $0 | After deductible | 50.0% | After deductible | YES |
| Non preferred brand | 3 month in retail | $0 | After deductible | 50.0% | After deductible | YES |
| Non preferred generic | 1 month in retail | $20.0 | Before deductible | 0% | Before deductible | YES |
| Non preferred generic | 3 month in mail | $60.0 | Before deductible | 0% | Before deductible | YES |
| Non preferred generic | 3 month in retail | $60.0 | Before deductible | 0% | Before deductible | YES |
| Non preferred specialty drugs | 1 month in retail | $0 | After deductible | 50.0% | After deductible | NO |
| Preferred brand | 1 month in retail | $75.0 | Before deductible | 0% | Before deductible | YES |
| Preferred brand | 3 month in mail | $225.0 | Before deductible | 0% | Before deductible | YES |
| Preferred brand | 3 month in retail | $225.0 | Before deductible | 0% | Before deductible | YES |
| Preferred generic | 1 month in retail | $3.0 | Before deductible | 0% | Before deductible | YES |
| Preferred generic | 3 month in mail | $9.0 | Before deductible | 0% | Before deductible | YES |
| Preferred generic | 3 month in retail | $9.0 | Before deductible | 0% | Before deductible | YES |
| Specialty drugs | 1 month in retail | $0 | After deductible | 50.0% | After deductible | NO |
| Zero cost share preventive drugs | 1 month in retail | $0 | Before deductible | 0% | Before deductible | YES |
| Zero cost share preventive drugs | 3 month in mail | $0 | Before deductible | 0% | Before deductible | YES |
| Zero cost share preventive drugs | 3 month in retail | $0 | Before deductible | 0% | Before deductible | YES |
Frequently Asked Questions(FAQ) about Gold Simple ($3 Drugs + $0 Virtual Care), 91908OK0010033 Health Insurance Plan, 91908OK0010033
Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, 91908OK0010033 support Mail Ordering?
Yes, Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance
Plan, 91908OK0010033 supports mail ordering for the next drug tiers: Non preferred brand, Non preferred generic, Preferred brand, Preferred generic, Zero cost share preventive drugs
What are the Generic Medications coinsurance & copay options with Gold Simple ($3 Drugs + $0 Virtual Care) (91908OK0010033) Health Insurance Plan?
For non preferred generic drug tier copay (Before deductible) is $20.0 and coinsurance (Before deductible) is 0.0%, non preferred generic drug tier copay (Before deductible) is $60.0 and coinsurance (Before deductible) is 0.0%, non preferred generic drug tier copay (Before deductible) is $60.0 and coinsurance (Before deductible) is 0.0%, preferred generic drug tier copay (Before deductible) is $3.0 and coinsurance (Before deductible) is 0.0%, preferred generic drug tier copay (Before deductible) is $9.0 and coinsurance (Before deductible) is 0.0%, preferred generic drug tier copay (Before deductible) is $9.0 and coinsurance (Before deductible) is 0.0%
What are the copay and coinsurance options for Brand Drugs with Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan (91908OK0010033)?
For non preferred brand drug tier copay (After deductible) is $0.0 and coinsurance (After deductible) is 50.0%, non preferred brand drug tier copay (After deductible) is $0.0 and coinsurance (After deductible) is 50.0%, non preferred brand drug tier copay (After deductible) is $0.0 and coinsurance (After deductible) is 50.0%, preferred brand drug tier copay (Before deductible) is $75.0 and coinsurance (Before deductible) is 0.0%, preferred brand drug tier copay (Before deductible) is $225.0 and coinsurance (Before deductible) is 0.0%, preferred brand drug tier copay (Before deductible) is $225.0 and coinsurance (Before deductible) is 0.0%
What are the copay and coinsurance options for Brand Drugs with Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan (91908OK0010033)?
, non preferred brand drug tier copay (After deductible) is $0.0 and coinsurance (After deductible) is 50.0%, non preferred brand drug tier copay (After deductible) is $0.0 and coinsurance (After deductible) is 50.0%, non preferred brand drug tier copay (After deductible) is $0.0 and coinsurance (After deductible) is 50.0%, preferred brand drug tier copay (Before deductible) is $75.0 and coinsurance (Before deductible) is 0.0%, preferred brand drug tier copay (Before deductible) is $225.0 and coinsurance (Before deductible) is 0.0%, preferred brand drug tier copay (Before deductible) is $225.0 and coinsurance (Before deductible) is 0.0%
Does (91908OK0010033) Health Insurance Plan, Variant (91908OK0010033-00) 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 (91908OK0010033) Health Insurance Plan, Variant (91908OK0010033-00) have Out Of Country Coverage?
Yes. Details: Emergency Services only.
Does (91908OK0010033) Health Insurance Plan, Variant (91908OK0010033-00) have Out of Service Area Coverage?
Yes. Details: Emergency and Urgent Services only.
Does (91908OK0010033) Health Insurance Plan, Variant (91908OK0010033-00) 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 Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-00) offer Disease Management Programs for Asthma?
Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-00 offers Disease Management Program for Asthma.
Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-00) offer Disease Management Programs for Heart disease?
Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-00 offers Disease Management Program for Heart disease.
Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-00) offer Disease Management Programs for Depression?
Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-00 offers Disease Management Program for Depression.
Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-00) offer Disease Management Programs for Diabetes?
Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-00 offers Disease Management Program for Diabetes.
Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-00 offers Disease Management Program for High blood pressure & high cholesterol.
Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-00) offer Disease Management Programs for Low back pain?
Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-00 offers Disease Management Program for Low back pain.
Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-00) offer Disease Management Programs for Pain management?
Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-00 offers Disease Management Program for Pain management.
Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-00) offer Disease Management Programs for Pregnancy?
Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-00 offers Disease Management Program for Pregnancy.
Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-00) offer Disease Management Programs for Weight loss programs?
Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-00 offers Disease Management Program for Weight loss programs.
Disclaimer: This is based on the import(Date: Tue, 21 Mar 2023 13:10 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