Silver Simple- For Diabetes - 91908OK0010045 Health Insurance Plan

Oscar Insurance Company health insurance plan with the Plan ID 91908OK0010045. The plan is called Silver Simple- For Diabetes.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.02% (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 5.98% 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 91908OK0010045
Health Insurance Plan Year 2023
State Oklahoma
Health Insurance Issuer Oscar Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 91908OK0010045-06
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 - 91908OK0010045-00

Standard On Exchange Plan - 91908OK0010045-01

Open to Indians below 300% FPL - 91908OK0010045-02

Open to Indians above 300% FPL - 91908OK0010045-03

73% AV Silver Plan - 91908OK0010045-04

87% AV Silver Plan - 91908OK0010045-05

94% AV Silver Plan - 91908OK0010045-06

Last Plan Update Date Fri, 24 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Silver Simple- For Diabetes Health Insurance Plan, 91908OK0010045-06

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

30.00%

50.00% Coinsurance after deductible
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

$5.00

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

30.00%

50.00% Coinsurance after deductible
Chiropractic Care
YES

$5.00

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

30.00%

50.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

NO
Diabetes Education
YES

$0.00

50.00% Coinsurance after deductible
Dialysis
YES

30.00%

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

30.00%

50.00% Coinsurance after deductible
Emergency Room Services
YES

30.00%

30.00%
Emergency Transportation/Ambulance
YES

30.00%

30.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

50.00%

50.00% Coinsurance after deductible
Gender Affirming Care
YES

30.00%

50.00% Coinsurance after deductible
Generic Drugs

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

YES

Tier 1: $0.00

Tier 2: $5.00

100.00%
Habilitation Services

Limit: 25.0 Visit(s) per Benefit Period

YES

30.00%

50.00% Coinsurance after deductible
Hearing Aids

One hearing aid per ear every 48 months.

YES

30.00%

50.00% Coinsurance after deductible
Home Health Care Services

Limit: 30.0 Visit(s) per Benefit Period

YES

$5.00

50.00% Coinsurance after deductible
Hospice Services
YES

30.00%

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

30.00%

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy

Limit: 25.0 Visit(s) per Benefit Period

Covered under Outpatient Therapy Services.

YES

30.00%

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

30.00%

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

30.00%

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services

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

YES

Tier 1: $5.00

Tier 2: $10.00

50.00% Coinsurance after deductible
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

30.00%

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

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

YES

$0.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs

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

YES

50.00%

100.00%
Nutritional Counseling

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

YES

$0.00

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$0.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

30.00%

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 30.0 Days per Benefit Period

YES

30.00%

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

30.00%

50.00% Coinsurance after deductible
Preferred Brand Drugs

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

YES

$15.00

100.00%
Prenatal and Postnatal Care
YES

$0.00

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

$0.00

50.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness

Virtual visits with an Oscar Care urgent care provider are unlimited and always $0?even if you haven?t hit your deductible. Depending on your plan, many prescriptions and labs will also cost you $0, if they?re ordered by your Oscar Virtual Urgent Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan.

YES

$0.00

50.00% Coinsurance after deductible
Private-Duty Nursing

Limit: 85.0 Visit(s) per Benefit Period

Pre-authorization required.

YES

$5.00

50.00% Coinsurance after deductible
Prosthetic Devices
YES

30.00%

50.00% Coinsurance after deductible
Radiation
YES

30.00%

50.00% Coinsurance after deductible
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

30.00%

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 25.0 Visit(s) per Benefit Period

Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).

YES

30.00%

50.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 25.0 Visit(s) per Benefit Period

Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).

YES

30.00%

50.00% Coinsurance after deductible
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

50.00% Coinsurance after deductible
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Benefit Period

YES

30.00%

50.00% Coinsurance after deductible
Specialist Visit

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

YES

$5.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

50.00%

100.00%
Substance Abuse Disorder Inpatient Services

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

YES

30.00%

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services

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

YES

$0.00

50.00% Coinsurance after deductible
Transplant
YES

30.00%

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$30.00

50.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00

50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

30.00%

50.00% Coinsurance after deductible

Silver Simple- For Diabetes ($0 Diabetic Labs + $100 Monthly Cap for Formulary Insulin + $0 Diabetic Foot and Eye Exams) Health Insurance Plan Variant 91908OK0010045-06 Attributes

Plan Attribute Value
AV Calculator Output Number 0.940194171
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 94% AV Level Silver 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 OKF001
Formulary URL URL
HIOS Product ID 91908OK001
Import Date 2/24/2023 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 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 Silver
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 91908OK0010045-06
Plan Marketing Name Silver Simple- For Diabetes
Plan Type PPO
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 $1,200
SBC Scenario, Having a Baby, Copayment $40
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 $500
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $800
SBC Scenario, Treatment of a Simple Fracture, Copayment $10
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 80%
Service Area ID OKS001
Source Name HIOS
Plan ID 91908OK0010045
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 30.00%
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, In Network (Tier 2), Default Coinsurance 30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $0
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $1000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $500 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $2400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $1200 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $1,200
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $2400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $1200 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $1,200
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 Silver Simple- For Diabetes Health Insurance Plan, 91908OK0010045

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

Frequently Asked Questions(FAQ) about Silver Simple- For Diabetes, 91908OK0010045 Health Insurance Plan, 91908OK0010045

  • Does Silver Simple- For Diabetes Health Insurance Plan, 91908OK0010045 support Mail Ordering?

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

  • Does (91908OK0010045) Health Insurance Plan, Variant (91908OK0010045-06) 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 (91908OK0010045) Health Insurance Plan, Variant (91908OK0010045-06) have Out Of Country Coverage?

    Yes. Details: Emergency Services only.

    Does (91908OK0010045) Health Insurance Plan, Variant (91908OK0010045-06) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services only.

    Does (91908OK0010045) Health Insurance Plan, Variant (91908OK0010045-06) 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 (91908OK0010045-06) 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 91908OK0010045-06 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 (91908OK0010045-06) 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 91908OK0010045-06 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 (91908OK0010045-06) 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 91908OK0010045-06 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 (91908OK0010045-06) 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 91908OK0010045-06 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 (91908OK0010045-06) 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 91908OK0010045-06 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 (91908OK0010045-06) 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 91908OK0010045-06 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 (91908OK0010045-06) 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 91908OK0010045-06 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 (91908OK0010045-06) 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 91908OK0010045-06 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