Arizona health plan · 2025

Bronze Elite + PCP Saver Plus · 13877AZ0070005

Oscar Health Plan, Inc. offers this marketplace health insurance plan (Plan ID 13877AZ0070005) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Expanded Bronze Plan type: HMO CSR: Zero Cost Sharing Plan Variation Issuer: Oscar Health Plan, Inc.
Telehealth Data pending HSA eligible No Dental Not listed Vision Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 100.00% (0.00% member share on average). Learn about AV methodology.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$207 – $919

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$0

$0 per group

Review MOOP rules

Office visits

Primary care $0.00
Specialist $0.00
HSA Not eligible

Drug tiers

Generic $0.00
Preferred brand $0.00

View formulary tiers

$293 / mo before subsidies

≈ $3519 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1017 / mo before subsidies

≈ $12205 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$1232 / mo before subsidies

≈ $14781 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$783 / mo before subsidies

≈ $9393 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

0.00%

Emergency Room Services

$0.00

Durable Medical Equipment

$0.00

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Arizona). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Zero Cost Sharing Plan Variation plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

0.00%

Emergency Room Services

$0.00

Durable Medical Equipment

$0.00

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 13877AZ0070005
Coverage year 2025
State Arizona
Issuer Oscar Health Plan, Inc.
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 13877AZ0070005-02
Available variants

Standard Off Exchange Plan · 13877AZ0070005-00

Standard On Exchange Plan · 13877AZ0070005-01

Open to Indians below 300% FPL · 13877AZ0070005-02

Open to Indians above 300% FPL · 13877AZ0070005-03
Last plan update Fri, 10 Jan 2025 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in Arizona 13
PCPs in Arizona 3
Telehealth support Data pending
Nationwide providers 14
13 doctors statewide 3 PCPs

Provider network(s)

Providers Arizona All US states
All 13 14
PCP 3 3
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A

Drug coverage overview

4,034 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
GENERIC 2,214
NON-PREFERRED-BRAND 624
SPECIALTY-DRUGS 587
PREFERRED-GENERIC 320
ZERO-COST-SHARE-PREVENTIVE-DRUGS 214
NONPREFERRED-SPECIALTY-DRUGS 75
Prior authorization Drugs
Required 884
Not Required 3,150
Step therapy Drugs
Required 19
Not Required 4,015
Quantity limits Drugs
Has Limit 1,457
No Limit 2,577

Customer highlights

What stands out for members

  • Issuer: Oscar Health Plan, Inc. · Plan ID 13877AZ0070005 · 2025 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, Pregnancy.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 13877AZ0070005-02 (Open to Indians below 300% FPL) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Limit: 20.0 Visit(s) per Year

HMOs may limit chiropractic visits to 20.

Exclusions: 1. Services of a chiropractor or osteopath which are not within his scope of practice, as defined by state law; 2. Charges for care not provided in an office setting; 3. Maintenance or preventive treatment consisting of routine, long term or Non-Medically Appropriate care provided to prevent recurrences or to maintain the patients current status; and 4. Vitamin therapy.

Diabetes Education

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Home Health Care Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Limit: 42.0 Visit(s) per Year

1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician. 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services. 3. The patient must be homebound unless services are determined to be medically necessary by the Medical Management Organization. 4. The home health agency delivering care must be certified within the state the care is received. 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of service.

Exclusions: Home health services do not include services of a person who is a member of your family or your dependents family or who normally resides in your house or your dependents house.

Laboratory Outpatient and Professional Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Preventive Care/Screening/Immunization

0.00%
Tier 1 in-network 0.00%
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Year

Well Woman and Well Man examinations are limited to 1 visit per year.

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Cost share applies to both in-person and telemedicine services. Virtual primary care services provided by Oscar-designated virtual care providers are covered in full. Virtual pediatric primary care services are not available through Oscar Medical Group; these services should be obtained in-person from in-network providers.

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Visit limit is for all therapy types combined (PT, OT, ST).

Exclusions: Occupational therapy is provided only for purposes of training Members to perform the activities of daily living.

Rehabilitative Speech Therapy

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Visit limit is for all therapy types combined (PT, OT, ST).

Exclusions: Speech therapy is not covered when: a. Used to improve speech skills that have not fully developed; b. Considered custodial or educational; c. Intended to maintain speech communication; or d. Not restorative in nature.

Specialist Visit

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Cost share applies to both in-person and telemedicine services.

Exclusions: nan

Urgent Care Centers or Facilities

$0.00
Tier 1 in-network $0.00
Out-of-network $0.00

Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full.

Exclusions: nan

X-rays and Diagnostic Imaging

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

The per day copayment will apply for a maximum of two (2) days. Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the Member is confirmed through a court order or legal guardianship

Exclusions: nan

Dialysis

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Durable Medical Equipment

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Breast Pumps covered in full

Exclusions: 1. Hygienic or self-help items or equipment; 2. Items or equipment primarily used for comfort or convenience such as bathtub chairs, safety grab bars, stair gliders or elevators, over-the-bed tables, saunas or exercise equipment; 3. Environmental control equipment, such as air purifiers, humidifiers and electrostatic machines; 4. Institutional equipment, such as air fluidized beds and diathermy machines; 5. Elastic stockings and wigs (except where indicated for coverage); 6. Equipment used for the purpose of participation in sports or other recreational activities including, but not limited to, braces and splints; 7. Items, such as auto tilt chairs, paraffin bath units and whirlpool baths, which are not generally accepted by the medical profession as being therapeutically effective; 8. Items which under normal use would constitute a fixture to real property, such as lifts, ramps, railings, and grab bars; and 9. Hearing aid batteries (except those for cochlear implants) and chargers.

Emergency Room Services

$0.00
Tier 1 in-network $0.00
Out-of-network $0.00

nan

Exclusions: nan

Emergency Transportation/Ambulance

$0.00
Tier 1 in-network $0.00
Out-of-network $0.00

nan

Exclusions: nan

Hospice Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live.

Exclusions: nan

Inpatient Hospital Services (e.g., Hospital Stay)

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

The per day copayment will apply for a maximum of two (2) days.

Exclusions: nan

Inpatient Physician and Surgical Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

The per day copayment will apply for a maximum of two (2) days.

Exclusions: 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy for age-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management

Mental/Behavioral Health Outpatient Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Exclusions: 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy for age-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management

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

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Outpatient Rehabilitation Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Short-term rehabilitative therapy includes services in an outpatient facility or physicians office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy. Visit limit is for all therapy types combined.

Exclusions: The following limitations apply to short-term rehabilitative therapy except as required for the treatment for Autism Spectrum Disorder: 1. Occupational therapy is provided only for purposes of training Members to perform the activities of daily living. 2. Speech therapy is not covered when: a. Used to improve speech skills that have not fully developed; b. Considered custodial or educational; c. Intended to maintain speech communication; or d. Not restorative in nature. 3. Phase 3 cardiac rehabilitation is not covered. If multiple services are provided on the same day by different Providers, a separate co-payment will apply to each Provider.

Outpatient Surgery Physician/Surgical Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Radiation

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Skilled Nursing Facility

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Limit: 90.0 Days per Year

The per day copayment will apply for a maximum of two (2) days.

Exclusions: nan

Substance Abuse Disorder Inpatient Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

The per day copayment will apply for a maximum of two (2) days.

Exclusions: 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy for age-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management

Substance Abuse Disorder Outpatient Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Exclusions: 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy for age-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management

Transplant

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipients medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as: 1. Allogeneic bone marrow/stem cell; 2. Autologous bone marrow/stem cell; 3. Cornea; 4. Heart; 5. Heart/lung; 6. Kidney; 7. Kidney/pancreas; 8. Liver; 9. Lung; 10. Pancreas; 11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non- experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.

Exclusions: These benefits are available when the Member is the recipient of an organ transplant. No coverage if Member is an organ donor for a recipient other than a Member enrolled under this plan. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Limit: 1.0 Item(s) per Benefit Period

Hearing aid devices limited to one per ear, per Plan Year when determined to be medically necessary by the Medical Management Organization.

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

0.00%
Tier 1 in-network 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Routine Eye Exam for Children

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Well Baby Visits and Care

0.00%
Tier 1 in-network 0.00%
Out-of-network 100.00%

Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$0.00
Tier 1 in-network $0.00
Tier 2 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Non-Preferred Brand Drugs

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Preferred Brand Drugs

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Specialty Drugs

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Benefits are payable for the services of a physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

Coverage details pending

nan

Exclusions: nan

Infusion Therapy

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Infusion/IV Therapy in an Outpatient setting including, but not limited to: Infliximab (Remicade), Alefacept (Amevive), and Etanercept (Enbrel).

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to: 1. Morbid obesity 2. Diabetes 3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year and $150 maximum. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear.

Exclusions: 1. Any biomechanical devices. Biomechanical devices are any external prosthetics operated through or in conjunction with nerve conduction or other electrical impulses; 2. Replacement of external prosthetic appliances due to loss or theft; and 3. Wigs or hairpieces (except where indicated in column"I").

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

"Voluntary termination of pregnancy" is excluded.

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Bariatric Surgery

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

1. The patient must have a body-mass index (BMI) greater than or equal to 35. 2. Have at least one co-morbidity related to obesity. 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient's medical record: Active participation within the last two years in one physician supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components: a. Weight b. Current dietary program c. Physical activity (e.g., exercise program) 4. In addition, the procedure must be performed at an approved Center of Excellence facility that is credentialed by your Health Network to perform bariatric surgery. 5. The member must be 18 years or older, or have reached full expected skeletal growth.

Exclusions: The following bariatric procedures are excluded: 1. Open vertical banded gastroplasty; 2. Laparoscopic vertical banded gastroplasty; 3. Open sleeve gastrectomy;4. Open adjustable gastric banding.

Cosmetic Surgery

Coverage details pending

nan

Exclusions: nan

Eye Glasses for Children

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

One (1) prescribed lenses and frames per Benefit Period. Contacts covered in lieu of glasses. $150 allowance for Lenses and Frames, or Contact Lenses."

Exclusions: nan

Gender Affirming Care

Coverage details pending

nan

Exclusions: nan

Habilitation Services

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

nan

Exclusions: nan

Infertility Treatment

Coverage details pending

nan

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan.

Exclusions: nan

Reconstructive Surgery

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Following a mastectomy, the following services and supplies are covered: 1. Surgical services for reconstruction of the breast on which the mastectomy was performed; 2. Surgical services for reconstruction of the non- diseased breast to produce symmetrical appearance; 3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs. During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury. Congenital defects and birth abnormalities are covered for Eligible Dependent children.

Exclusions: nan

Routine Eye Exam (Adult)

Coverage details pending

nan

Exclusions: nan

Routine Foot Care

Coverage details pending

nan

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of: 1. An accident; 2. Trauma; 3. A congenital defect; 4. A developmental defect; or 5. A pathology.

Exclusions: nan

Variant attributes

Bronze Elite + PCP Saver Plus · Variant 13877AZ0070005-02

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Zero Cost Sharing Plan Variation

HIOS Product ID

13877AZ007

Metal Level

Expanded Bronze

Plan ID (Standard Component ID with Variant)

13877AZ0070005-02

Plan Marketing Name

Bronze Elite + PCP Saver Plus

Plan Variant Marketing Name

AIAN Cost Share

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

13877

Issuer Marketplace Marketing Name

Oscar Health Plan, Inc.

Market Coverage

Individual

Multiple In Network Tiers

Yes

National Network

No

Network ID

AZN001

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

Service Area ID

AZS001

State Code

AZ

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

1.0

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

0.00%

Drug EHB Deductible, In Network (Tier 2), Default Coinsurance

0.00%

Inpatient Copayment Maximum Days

2

Medical Drug Deductibles Integrated

No

Medical Drug Maximum Out of Pocket Integrated

Yes

Medical EHB Deductible, In Network (Tier 1), Default Coinsurance

0.00%

Medical EHB Deductible, In Network (Tier 2), Default Coinsurance

0.00%

SBC Scenario, Having a Baby, Coinsurance

$0

SBC Scenario, Having a Baby, Copayment

$0

SBC Scenario, Having a Baby, Deductible

$0

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$0

SBC Scenario, Having Diabetes, Deductible

$0

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$0

SBC Scenario, Treatment of a Simple Fracture, Copayment

$0

SBC Scenario, Treatment of a Simple Fracture, Deductible

$0

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

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$0 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$0 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$0

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group

$0 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person

$0 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual

$0

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

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

AZF001

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$0

SBC Scenario, Having Diabetes, Limit

$0

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Drug EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Drug EHB Deductible, In Network (Tier 1), Family Per Group

$0 per group

Drug EHB Deductible, In Network (Tier 1), Family Per Person

$0 per person

Drug EHB Deductible, In Network (Tier 1), Individual

$0

Drug EHB Deductible, In Network (Tier 2), Family Per Group

$0 per group

Drug EHB Deductible, In Network (Tier 2), Family Per Person

$0 per person

Drug EHB Deductible, In Network (Tier 2), Individual

$0

Drug EHB Deductible, Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Out of Network, Individual

Not Applicable

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, Pregnancy

EHB Percent of Total Premium

1.0

First Tier Utilization

44%

Import Date

2025-01-10 00:01:52

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

Medical EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Medical EHB Deductible, In Network (Tier 1), Family Per Group

$0 per group

Medical EHB Deductible, In Network (Tier 1), Family Per Person

$0 per person

Medical EHB Deductible, In Network (Tier 1), Individual

$0

Medical EHB Deductible, In Network (Tier 2), Family Per Group

$0 per group

Medical EHB Deductible, In Network (Tier 2), Family Per Person

$0 per person

Medical EHB Deductible, In Network (Tier 2), Individual

$0

Medical EHB Deductible, Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Out of Network, Individual

Not Applicable

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

HMO

QHP/Non QHP

Both

Second Tier Utilization

56%

Source Name

HIOS

Plan ID

13877AZ0070005

Unique Plan Design

No

Wellness Program Offered

No

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in Arizona?

Bronze Elite + PCP Saver Plus (13877AZ0070005) is a Expanded Bronze HMO from Oscar Health Plan, Inc. in Arizona for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does Bronze Elite + PCP Saver Plus support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is Bronze Elite + PCP Saver Plus HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental coverage is not listed for this plan.

Vision add-ons: Child.

Does Bronze Elite + PCP Saver Plus support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with Bronze Elite + PCP Saver Plus?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, Pregnancy.

Is there out-of-country coverage for Bronze Elite + PCP Saver Plus?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Emergency Services Only

Does Bronze Elite + PCP Saver Plus cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Emergency and Urgent Services Only

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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