Gold Simple - 91908OK0010033 Health Insurance Plan

Oscar Insurance Company health insurance plan with the Plan ID 91908OK0010033. The plan is called Gold Simple.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 76.32% (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 23.68% 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 91908OK0010033
Health Insurance Plan Year 2022
State Oklahoma
Health Insurance Issuer Oscar Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 91908OK0010033-03
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 - 91908OK0010033-00

Standard On Exchange Plan - 91908OK0010033-01

Open to Indians below 300% FPL - 91908OK0010033-02

Open to Indians above 300% FPL - 91908OK0010033-03

Last Plan Update Date Wed, 18 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-03 Attributes

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 Limited Cost Sharing Plan Variation
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) 91908OK0010033-03
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
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $16000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $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

Copay & Coinsurance of Gold Simple Health Insurance Plan, 91908OK0010033

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

Frequently Asked Questions(FAQ) about Gold Simple, 91908OK0010033 Health Insurance Plan, 91908OK0010033

  • Does Gold Simple Health Insurance Plan, 91908OK0010033 support Mail Ordering?

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

  • Does (91908OK0010033) Health Insurance Plan, Variant (91908OK0010033-03) 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 (91908OK0010033-03) have Out Of Country Coverage?

    Yes. Details: Emergency Services only.

    Does (91908OK0010033) Health Insurance Plan, Variant (91908OK0010033-03) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services only.

    Does (91908OK0010033) Health Insurance Plan, Variant (91908OK0010033-03) 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 (91908OK0010033-03) offer Disease Management Programs for Asthma?

    Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-03 offers Disease Management Program for Asthma.

    Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-03) offer Disease Management Programs for Heart disease?

    Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-03 offers Disease Management Program for Heart disease.

    Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-03) offer Disease Management Programs for Depression?

    Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-03 offers Disease Management Program for Depression.

    Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-03) offer Disease Management Programs for Diabetes?

    Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-03 offers Disease Management Program for Diabetes.

    Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-03) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-03 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-03) offer Disease Management Programs for Low back pain?

    Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-03 offers Disease Management Program for Low back pain.

    Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-03) offer Disease Management Programs for Pregnancy?

    Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-03 offers Disease Management Program for Pregnancy.

    Does Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (91908OK0010033-03) offer Disease Management Programs for Weight loss programs?

    Yes, the Gold Simple ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 91908OK0010033-03 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