Silver Simple- For Diabetes - 58081GA0010045 Health Insurance Plan

Oscar Health Plan of Georgia health insurance plan with the Plan ID 58081GA0010045. The plan is called Silver Simple- For Diabetes.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.21% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.79% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.09% (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 29.91% 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 58081GA0010045
Health Insurance Plan Year 2023
State Georgia
Health Insurance Issuer Oscar Health Plan of Georgia
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 58081GA0010045-00
Provider Network(s) ['GAN001']
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 Georgia 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 - 58081GA0010045-00

Standard On Exchange Plan - 58081GA0010045-01

Open to Indians below 300% FPL - 58081GA0010045-02

Open to Indians above 300% FPL - 58081GA0010045-03

73% AV Silver Plan - 58081GA0010045-04

87% AV Silver Plan - 58081GA0010045-05

94% AV Silver Plan - 58081GA0010045-06

Last Plan Update Date Wed, 01 Mar 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Silver Simple- For Diabetes Health Insurance Plan, 58081GA0010045-00

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

50.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$40.00

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

50.00% Coinsurance after deductible

100.00%
Chiropractic Care
NO
Cosmetic Surgery
YES

50.00% Coinsurance after deductible

100.00%
Delivery and All Inpatient Services for Maternity Care
YES

50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Procedure(s) per Year

NO
Diabetes Education
YES

$0.00

100.00%
Dialysis
YES

50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

50.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

50.00%

100.00%
Gender Affirming Care
YES

50.00% Coinsurance after deductible

100.00%
Generic Drugs

Covered prescription insulin drugs are limited to a $100 copayment maximum per 30-day supply.

YES

Tier 1: $0.00

Tier 2: $25.00

100.00%
Habilitation Services

Limit: 40.0 Visit(s) per Year

Habilitative services apply toward the 'Physical medicine and rehabilitative services' maximum number of visits specified in the 'Schedule of Benefits'.

YES

50.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 120.0 Visit(s) per Year

YES

$40.00

100.00%
Hospice Services
YES

50.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Insulin infusion devices.

YES

50.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Labs (HbA1c screening, urinalysis, metabolic panel, lipid panel) to manage diabetes are covered in full.

YES

Tier 1: $10.00

Tier 2: $65.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$0.00

100.00%
Non-Preferred Brand Drugs

Covered prescription insulin drugs are limited to a $100 copayment maximum per 30-day supply.

YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Limit: 4.0 Visit(s) per Year

YES

$0.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Only covers orthodontic treatment for a congenital anomaly related to or developed as a result of cleft palate, with or without cleft lip.

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

$0.00

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

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 40.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Covered prescription insulin drugs are limited to a $100 copayment maximum per 30-day supply.

YES

$75.00 Copay after deductible

100.00%
Prenatal and Postnatal Care
YES

$0.00

100.00%
Preventive Care/Screening/Immunization

The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).

YES

$0.00

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$0.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 40.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

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

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit

Diabetic eye exam and diabetic foot exams are covered in full.

YES

$40.00

100.00%
Specialty Drugs
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00

100.00%
Transplant

Limit: 10000.0 Dollars per Procedure

Limited to a combined maximum of $10,000 per covered organ transplant.

YES

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$75.00

100.00%
Weight Loss Programs

Limit: 4.0 Visit(s) per Year

Nutritional counseling for the treatment of obesity, which includes morbid obesity.

YES 100.00%
Well Baby Visits and Care

Care provided for birth through age 5.

YES

$0.00

100.00%
X-rays and Diagnostic Imaging
YES

50.00% Coinsurance after deductible

100.00%

Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan Variant 58081GA0010045-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.70093858
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 Silver Off Exchange Plan
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 1
First Tier Utilization 20%
Formulary ID GAF001
Formulary URL URL
HIOS Product ID 58081GA001
Import Date 3/1/2023 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 70.21%
Issuer ID 58081
Issuer Marketplace Marketing Name Oscar Health Plan of Georgia
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers Yes
National Network No
Network ID GAN001
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) 58081GA0010045-00
Plan Marketing Name Silver Simple- For Diabetes
Plan Type HMO
Plan Variant Marketing Name Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,900
SBC Scenario, Having a Baby, Copayment $200
SBC Scenario, Having a Baby, Deductible $6,450
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $200
SBC Scenario, Having Diabetes, Deductible $4,200
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $80
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,600
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 80%
Service Area ID GAS001
Source Name HIOS
Plan ID 58081GA0010045
State Code GA
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $12900 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $6450 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $6,450
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $12900 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $6450 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $6,450
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 $17100 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8550 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,550
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $17100 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8550 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,550
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Silver Simple- For Diabetes Health Insurance Plan, 58081GA0010045

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

Frequently Asked Questions(FAQ) about Silver Simple- For Diabetes, 58081GA0010045 Health Insurance Plan, 58081GA0010045

  • Does Silver Simple- For Diabetes Health Insurance Plan, 58081GA0010045 support Mail Ordering?

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

  • Does (58081GA0010045) Health Insurance Plan, Variant (58081GA0010045-00) 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 (58081GA0010045) Health Insurance Plan, Variant (58081GA0010045-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services only

    Does (58081GA0010045) Health Insurance Plan, Variant (58081GA0010045-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services only

    Does (58081GA0010045) Health Insurance Plan, Variant (58081GA0010045-00) 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 Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan, Variant (58081GA0010045-00) offer Disease Management Programs for Asthma?

    Yes, the Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan Variant 58081GA0010045-00 offers Disease Management Program for Asthma.

    Does Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan, Variant (58081GA0010045-00) offer Disease Management Programs for Heart disease?

    Yes, the Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan Variant 58081GA0010045-00 offers Disease Management Program for Heart disease.

    Does Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan, Variant (58081GA0010045-00) offer Disease Management Programs for Depression?

    Yes, the Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan Variant 58081GA0010045-00 offers Disease Management Program for Depression.

    Does Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan, Variant (58081GA0010045-00) offer Disease Management Programs for Diabetes?

    Yes, the Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan Variant 58081GA0010045-00 offers Disease Management Program for Diabetes.

    Does Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan, Variant (58081GA0010045-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan Variant 58081GA0010045-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan, Variant (58081GA0010045-00) offer Disease Management Programs for Low back pain?

    Yes, the Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan Variant 58081GA0010045-00 offers Disease Management Program for Low back pain.

    Does Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan, Variant (58081GA0010045-00) offer Disease Management Programs for Pregnancy?

    Yes, the Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan Variant 58081GA0010045-00 offers Disease Management Program for Pregnancy.

    Does Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan, Variant (58081GA0010045-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan Variant 58081GA0010045-00 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