Friday Silver HSA - 91538OK0010014 Health Insurance Plan

Friday Health Insurance Company, Inc. health insurance plan with the Plan ID 91538OK0010014. The plan is called Friday Silver HSA.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.25% (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 26.75% 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 91538OK0010014
Health Insurance Plan Year 2023
State Oklahoma
Health Insurance Issuer Friday Health Insurance Company, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 91538OK0010014-04
Provider Network(s) ['OKN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Jul 2024 06:14 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 - 91538OK0010014-00

Standard On Exchange Plan - 91538OK0010014-01

Open to Indians below 300% FPL - 91538OK0010014-02

Open to Indians above 300% FPL - 91538OK0010014-03

73% AV Silver Plan - 91538OK0010014-04

87% AV Silver Plan - 91538OK0010014-05

94% AV Silver Plan - 91538OK0010014-06

Last Plan Update Date Sat, 08 Oct 2022 00:00 GMT
Last Import Date Tue, 16 Jul 2024 06:14 GMT

Benefits of Friday Silver HSA Health Insurance Plan, 91538OK0010014-04

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

Issuer clarifies this is a covered benefit but stipulated under the Medical Policy and not written in the member materials.

YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Chiropractic Care

Prior authorization after 30 visits

YES

20.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

20.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

NO
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

20.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Only Durable Medical Equipment considered standard and/or basic as defined by nationally recognized guidelines are covered.

YES

20.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
YES

20.00% Coinsurance after deductible

100.00%
Generic Drugs

Up to 30-day supply Retail and up to 90-day supply Retail & Mail Order, except narcotics and Specialty Drugs.

YES

No Charge after deductible

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Year

YES

20.00% Coinsurance after deductible

100.00%
Hearing Aids

One hearing aid per ear every 48 months.

YES

20.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 30.0 Visit(s) per Benefit Period

YES

20.00% Coinsurance after deductible

100.00%
Hospice Services
YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Limit: 25.0 Visit(s) per Benefit Period

Covered under Outpatient Therapy Services.

YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

20.00% Coinsurance after deductible

100.00%
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

20.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

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

YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs

Up to 30-day supply Retail and up to 90-day supply Retail & Mail Order, except narcotics and Specialty Drugs.

YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling

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

YES

20.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge after deductible

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

20.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Year

Maximum of 30 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).

YES

20.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Up to 30-day supply Retail and up to 90-day supply Retail & Mail Order, except narcotics and Specialty Drugs. Insulin will not exceed $30 for a 30-day supply and $90 for a 90-day supply.

YES

20.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

20.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

No Charge after deductible

100.00%
Private-Duty Nursing

Limit: 85.0 Visit(s) per Benefit Period

Pre-authorization required.

YES

20.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

20.00% Coinsurance after deductible

100.00%
Radiation
YES

20.00% Coinsurance after deductible

100.00%
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

20.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

Maximum of 30 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).

YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

Maximum of 30 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).

YES

20.00% 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

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Benefit Period

YES

20.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

20.00% Coinsurance after deductible

100.00%
Specialty Drugs

Up to 30-day supply Retail only.

YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

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

YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

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

YES

No Charge after deductible

100.00%
Transplant
YES

20.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$75.00 Copay after deductible

$75.00 Copay after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

20.00% Coinsurance after deductible

100.00%

FRIDAY Silver H 73% AV Health Insurance Plan Variant 91538OK0010014-04 Attributes

Plan Attribute Value
AV Calculator Output Number 0.732468928
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 73% AV Level Silver Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Diabetes
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID OKF005
Formulary URL URL
HIOS Product ID 91538OK001
Import Date 10/8/2022 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 91538
Issuer Marketplace Marketing Name Friday Health Plans
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID OKN001
Out of Country Coverage Yes
Out of Country Coverage Description Urgent and Emergent only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Urgent and Emergent only
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 91538OK0010014-04
Plan Marketing Name Friday Silver HSA
Plan Type HMO
Plan Variant Marketing Name FRIDAY Silver H 73% AV
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,000
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $2,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $1,100
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $2,500
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $60
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OKS001
Source Name HIOS
Plan ID 91538OK0010014
State Code OK
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $13000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $6500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $6,500
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $5000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $2500 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $2,500
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $5000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,500
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 $13000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,500
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 Yes

Copay & Coinsurance of Friday Silver HSA Health Insurance Plan, 91538OK0010014

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

Frequently Asked Questions(FAQ) about Friday Silver HSA, 91538OK0010014 Health Insurance Plan, 91538OK0010014

  • Does Friday Silver HSA Health Insurance Plan, 91538OK0010014 support Mail Ordering?

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

  • Does (91538OK0010014) Health Insurance Plan, Variant (91538OK0010014-04) offer Disease Management Programs?

    Yes, and here is the list of available programs: Diabetes

    Does (91538OK0010014) Health Insurance Plan, Variant (91538OK0010014-04) have Out Of Country Coverage?

    Yes. Details: Urgent and Emergent only

    Does (91538OK0010014) Health Insurance Plan, Variant (91538OK0010014-04) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergent only

    Does (91538OK0010014) Health Insurance Plan, Variant (91538OK0010014-04) offer Disease Management Programs?

    Yes, and here is the list of available programs: Diabetes

    Does FRIDAY Silver H 73% AV Health Insurance Plan, Variant (91538OK0010014-04) offer Disease Management Programs for Diabetes?

    Yes, the FRIDAY Silver H 73% AV Health Insurance Plan Variant 91538OK0010014-04 offers Disease Management Program for Diabetes.

 

Disclaimer: This is based on the import(Date: Tue, 16 Jul 2024 06:14 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