Ohio health plan · 2025

HDHP Preventive Silver 5500 $0 Select Drugs · 77552OH0010219

CareSource offers this marketplace health insurance plan (Plan ID 77552OH0010219) 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: Silver Plan type: HMO CSR: 94% AV Level Silver Plan Issuer: CareSource
Telehealth Data pending HSA eligible No Dental Not listed Vision Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 94.00% (6.00% 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

$303 – $1621

Before subsidies

Estimate after subsidies

Deductible

$700

$1400 per group

See deductible details

Max out-of-pocket

$700

$1400 per group

Review MOOP rules

Office visits

Primary care No Charge after deductible
Specialist No Charge after deductible
HSA Not eligible

Drug tiers

Generic No Charge after deductible
Preferred brand No Charge after deductible

View formulary tiers

$516 / mo before subsidies

≈ $6195 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.

$1702 / mo before subsidies

≈ $20418 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.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$2047 / mo before subsidies

≈ $24564 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.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1323 / mo before subsidies

≈ $15875 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

No Charge after deductible

Durable Medical Equipment

No Charge after deductible

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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 Ohio). 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.
  • 94% AV Level Silver Plan 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

No Charge after deductible

Durable Medical Equipment

No Charge after deductible

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 77552OH0010219
Coverage year 2025
State Ohio
Issuer CareSource
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 77552OH0010219-06
Available variants

Standard Off Exchange Plan · 77552OH0010219-00

Standard On Exchange Plan · 77552OH0010219-01

Open to Indians below 300% FPL · 77552OH0010219-02

Open to Indians above 300% FPL · 77552OH0010219-03

73% AV Silver Plan · 77552OH0010219-04

87% AV Silver Plan · 77552OH0010219-05

94% AV Silver Plan · 77552OH0010219-06
Last plan update Wed, 09 Oct 2024 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 Ohio 1301
PCPs in Ohio 234
Telehealth support Data pending
Nationwide providers 1565
1,301 doctors statewide 234 PCPs 23 OB/GYN

Provider network(s)

Providers Ohio All US states
All 1301 1565
PCP 234 281
Allergy 2 2
OB/GYN 23 30
Dentists N/A N/A

Drug coverage overview

4,242 drugs tracked

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

Tier Covered drugs
GENERIC 2,735
NON-PREFERRED-BRAND 572
MEDICAL-SERVICE-DRUGS 560
SPECIALTY-DRUGS 375
Prior authorization Drugs
Required 778
Not Required 3,464
Step therapy Drugs
Required 226
Not Required 4,016
Quantity limits Drugs
Has Limit 1,389
No Limit 2,853

Customer highlights

What stands out for members

  • Issuer: CareSource · Plan ID 77552OH0010219 · 2025 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 77552OH0010219-06 (94% AV Silver Plan ) currently displayed.
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Benefits

Covered services & limitations

Everyday care

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

Chiropractic Care

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Limit: 12.0 Visit(s) per Benefit Period

12 visits per benefit period for manipulation services. Cost share includes all Covered Services rendered during the visit with a Chiropractor (aka Chiropractor Services) including but not limited to the office visit, manipulation therapy, physical therapy services. Benefits limits will apply based on the type of services rendered. See the EOC for additional details.

Exclusions: nan

Diabetes Education

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition.

Exclusions: nan

Home Health Care Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Limit: 100.0 Visit(s) per Benefit Period

When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting.

Exclusions: nan

Laboratory Outpatient and Professional Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

No Charge after deductible
Tier 1 in-network No Charge after deductible
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%

Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women's contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9.

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Limit: 40.0 Visit(s) per Benefit Period

Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period.

Exclusions: nan

Rehabilitative Speech Therapy

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Limit: 20.0 Visit(s) per Benefit Period

nan

Exclusions: nan

Specialist Visit

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Urgent Care Centers or Facilities

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network No Charge after deductible

nan

Exclusions: nan

X-rays and Diagnostic Imaging

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care.

Exclusions: nan

Dialysis

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Benefits include supportive use of an artificial kidney machine.

Exclusions: nan

Durable Medical Equipment

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women's Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant.

Exclusions: nan

Emergency Room Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network No Charge after deductible

nan

Exclusions: nan

Emergency Transportation/Ambulance

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network No Charge after deductible

Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member's condition.

Exclusions: nan

Hospice Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician.

Exclusions: nan

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

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services.

Exclusions: nan

Inpatient Physician and Surgical Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician.

Exclusions: nan

Mental/Behavioral Health Inpatient Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

Exclusions: nan

Mental/Behavioral Health Outpatient Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

The cost sharing that displays applies to office visits only. All other services are subject to the Outpatient Professional Services cost share. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

Exclusions: nan

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

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient's medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient

Exclusions: nan

Outpatient Rehabilitation Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Benefit Period

Physical, Occupational and Speech Therapy limited to 20 visits each. Pulmonary Therapy limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Cardiac Rehabilitation limited to 36 visits. Cognitive Therapy limited to 20 visits. Manipulation Therapy is limited to 12 visits. Post Cochlear Rehabilitation limited to 30 visits. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document.

Exclusions: nan

Radiation

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Skilled Nursing Facility

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Limit: 90.0 Days per Benefit Period

Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies.

Exclusions: nan

Substance Abuse Disorder Inpatient Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

Exclusions: nan

Substance Abuse Disorder Outpatient Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

The cost sharing that displays applies to office visits only. All other services are subject to the Outpatient Professional Services cost share. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

Exclusions: nan

Transplant

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants (except cornea and kidney transplants) and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate. Covered the same as office visits, inpatient services, and outpatient services.

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

Coverage details pending

nan

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient's discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening).

Exclusions: nan

Routine Eye Exam for Children

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

Limit: 1.0 Exam(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.

Exclusions: nan

Well Baby Visits and Care

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

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. Select Preventive Drugs and Supplies are covered at no charge. Refer to the plan brochure for more information.

Exclusions: nan

Non-Preferred Brand Drugs

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

Exclusions: nan

Preferred Brand Drugs

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

Exclusions: nan

Specialty Drugs

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Limit: 3000.0 Dollars per Episode

Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law; coverage includes oral examinations, x-rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular/maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient's medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient.

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

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy.

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors).

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part.

Exclusions: nan

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

Coverage for nontherapeutic abortion is prohibited for Qualified Health Plans per Ohio Revised Code Section 3901.87.

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Bariatric Surgery

Coverage details pending

nan

Exclusions: nan

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%

Limit: 1.0 Item(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.

Exclusions: nan

Gender Affirming Care

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Surgery determined to be Medically Necessary is Covered

Exclusions: nan

Habilitation Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Physical, Occupational, and Speech Therapy limited to 20 visits each. Occupational and Speech Therapy for Autism Spectrum Disorder is limited to 20 visits each.

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Infertility Treatment

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 (A)(1)(h), and must be provided in accordance with Ohio Department of Insurance Bulletin No. 2009-07.

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Limit: 90.0 Visit(s) per Benefit Period

Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit; Quantitative Limit has been determined as 90 - 110 visits per year and represents the number of visits to meet the established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply.

Exclusions: nan

Reconstructive Surgery

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy.

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

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders. Covered the same as office visits, inpatient services, and outpatient services.

Exclusions: nan

Variant attributes

HDHP Preventive Silver 5500 $0 Select Drugs · Variant 77552OH0010219-06

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

94% AV Level Silver Plan

HIOS Product ID

77552OH001

Metal Level

Silver

Plan ID (Standard Component ID with Variant)

77552OH0010219-06

Plan Marketing Name

HDHP Preventive Silver 5500 $0 Select Drugs

Plan Variant Marketing Name

Preventive Silver 700 $0 Select Drugs

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

77552

Issuer Marketplace Marketing Name

CareSource

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

No

Network ID

OHN001

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 Services Only

Service Area ID

OHS001

State Code

OH

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.940037666101759

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

Yes

Medical Drug Maximum Out of Pocket Integrated

Yes

SBC Scenario, Having a Baby, Coinsurance

$0

SBC Scenario, Having a Baby, Copayment

$0

SBC Scenario, Having a Baby, Deductible

$700

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$0

SBC Scenario, Having Diabetes, Deductible

$700

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

$700

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

$1400 per group

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

$700 per person

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

$700

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

0.00%

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

$1400 per group

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

$700 per person

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

$700

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

OHF010

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

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

EHB Percent of Total Premium

1.0

First Tier Utilization

100%

Import Date

2024-10-09 20:01:46

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

New

Notice Required for Pregnancy

Yes

Is a Referral Required for Specialist?

No

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

HMO

QHP/Non QHP

Both

Source Name

SERFF

Plan ID

77552OH0010219

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

$1400 per group

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

$700 per person

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

$700

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

$1400 per group

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

$700 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual

$700

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

Unique Plan Design

No

Wellness Program Offered

Yes

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 Ohio?

HDHP Preventive Silver 5500 $0 Select Drugs (77552OH0010219) is a Silver HMO from CareSource in Ohio 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 HDHP Preventive Silver 5500 $0 Select Drugs 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 HDHP Preventive Silver 5500 $0 Select Drugs 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 HDHP Preventive Silver 5500 $0 Select Drugs 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 HDHP Preventive Silver 5500 $0 Select Drugs?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy.

Is there out-of-country coverage for HDHP Preventive Silver 5500 $0 Select Drugs?

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

Does HDHP Preventive Silver 5500 $0 Select Drugs 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 Services Only

How do I enroll in or manage payments for HDHP Preventive Silver 5500 $0 Select Drugs?

Use the issuer portal https://enroll.caresource.com to pay premiums or start enrollment, then return to HealthPorta for benefit comparisons.

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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