Oklahoma health plan · 2025

MyBlue Bronze HMO℠ 904 · 87571OK0510085

Blue Cross Blue Shield of Oklahoma offers this marketplace health insurance plan (Plan ID 87571OK0510085) 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: Bronze Plan type: HMO CSR: Standard Bronze Off Exchange Plan Issuer: Blue Cross Blue Shield of Oklahoma
Telehealth Data pending HSA eligible No Dental Not listed Vision Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 61.76% (38.24% 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

$246 – $964

Before subsidies

Estimate after subsidies

Deductible

$4,500

$9000 per group

See deductible details

Max out-of-pocket

$9,200

$18400 per group

Review MOOP rules

Office visits

Primary care $50.00
Specialist 40.00% Coinsurance after deductible
HSA Not eligible

Drug tiers

Generic 20.00% Coinsurance after deductible
Preferred brand 30.00% Coinsurance after deductible

View formulary tiers

$337 / mo before subsidies

≈ $4040 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.

$1067 / mo before subsidies

≈ $12801 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.

$1292 / mo before subsidies

≈ $15503 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.

$821 / mo before subsidies

≈ $9852 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

No Charge

Emergency Room Services

$950.00 Copay with deductible, 40.00% Coinsurance after deductible

Durable Medical Equipment

40.00% Coinsurance 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 Oklahoma). 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.
  • Standard Bronze Off Exchange 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

No Charge

Emergency Room Services

$950.00 Copay with deductible, 40.00% Coinsurance after deductible

Durable Medical Equipment

40.00% Coinsurance 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 87571OK0510085
Coverage year 2025
State Oklahoma
Issuer Blue Cross Blue Shield of Oklahoma
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 87571OK0510085-00
Available variants

Standard Off Exchange Plan · 87571OK0510085-00

Standard On Exchange Plan · 87571OK0510085-01

Open to Indians below 300% FPL · 87571OK0510085-02

Open to Indians above 300% FPL · 87571OK0510085-03
Last plan update Sat, 11 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 Oklahoma 12886
PCPs in Oklahoma 1045
Telehealth support Data pending
Nationwide providers 14446
12,886 doctors statewide 1,045 PCPs 24 OB/GYN

Provider network(s)

Providers Oklahoma All US states
All 12886 14446
PCP 1045 1224
Allergy 6 6
OB/GYN 24 26
Dentists 35 247

Drug coverage overview

3,933 drugs tracked

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

Tier Covered drugs
NON-PREFERRED-GENERIC 2,300
NON-PREFERRED-SPECIALTY 900
NON-PREFERRED-BRAND 733
Prior authorization Drugs
Required 941
Not Required 2,992
Step therapy Drugs
Required 28
Not Required 3,905
Quantity limits Drugs
Has Limit 1,665
No Limit 2,268

Customer highlights

What stands out for members

  • Issuer: Blue Cross Blue Shield of Oklahoma · Plan ID 87571OK0510085 · 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 87571OK0510085-00 (Standard Off Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Everyday care

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

Chiropractic Care

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 25.0 Visit(s) per Benefit Period

Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

Exclusions: nan

Diabetes Education

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Home Health Care Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Benefit Period

nan

Exclusions: nan

Laboratory Outpatient and Professional Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Preventive Care/Screening/Immunization

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

nan

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

nan

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

Limit: 25.0 Visit(s) per Benefit Period

Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

Exclusions: nan

Rehabilitative Speech Therapy

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

Limit: 25.0 Visit(s) per Benefit Period

Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

Exclusions: nan

Specialist Visit

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Urgent Care Centers or Facilities

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

X-rays and Diagnostic Imaging

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

$400.00 Copay with deductible, 40.00% Coinsurance after deductible
Tier 1 in-network $400.00 Copay with deductible, 40.00% Coinsurance after deductible
Out-of-network 100.00%

Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable. Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Exclusions: nan

Dialysis

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Durable Medical Equipment

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Emergency Room Services

$950.00 Copay with deductible, 40.00% Coinsurance after deductible
Tier 1 in-network $950.00 Copay with deductible, 40.00% Coinsurance after deductible
Out-of-network $950.00 Copay with deductible, 40.00% Coinsurance after deductible

Member will be responsible for copay per outpatient surgery service before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Exclusions: nan

Emergency Transportation/Ambulance

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details.

Exclusions: nan

Hospice Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

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

$400.00 Copay per Stay with deductible, 40.00% Coinsurance after deductible
Tier 1 in-network $400.00 Copay per Stay with deductible, 40.00% Coinsurance after deductible
Out-of-network 100.00%

Member will be responsible for copay per outpatient surgery service before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Exclusions: nan

Inpatient Physician and Surgical Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

$400.00 Copay per Stay with deductible, 40.00% Coinsurance after deductible
Tier 1 in-network $400.00 Copay per Stay with deductible, 40.00% Coinsurance after deductible
Out-of-network 100.00%

Member cost share may increase when using a setting other than office. Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Exclusions: nan

Mental/Behavioral Health Outpatient Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Member cost share may increase when using a setting other than office.

Exclusions: nan

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

$300.00 Copay with deductible, 30.00% Coinsurance after deductible
Tier 1 in-network $300.00 Copay with deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. Member will be responsible for copay per outpatient surgery admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Exclusions: nan

Outpatient Rehabilitation Services

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

Limit: 25.0 Visit(s) per Benefit Period

Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

$200.00 Copay with deductible, 40.00% Coinsurance after deductible
Tier 1 in-network $200.00 Copay with deductible, 40.00% Coinsurance after deductible
Out-of-network 100.00%

Member will be responsible for copay per outpatient surgery service before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Exclusions: nan

Radiation

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Skilled Nursing Facility

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 30.0 Days per Benefit Period

nan

Exclusions: nan

Substance Abuse Disorder Inpatient Services

$400.00 Copay per Stay with deductible, 40.00% Coinsurance after deductible
Tier 1 in-network $400.00 Copay per Stay with deductible, 40.00% Coinsurance after deductible
Out-of-network 100.00%

Member cost share may increase when using a setting other than office. Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Exclusions: nan

Substance Abuse Disorder Outpatient Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Member cost share may increase when using a setting other than office.

Exclusions: nan

Transplant

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

1 hearing aid per ear (2 hearing aids) every 48 months for any covered member.

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.

Exclusions: nan

Routine Eye Exam for Children

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

Limit: 1.0 Visit(s) per Benefit Period

When purchasing Out of Network, reimbursements are available. See benefit book for details

Exclusions: nan

Well Baby Visits and Care

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

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Tier 2 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Certain generic drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Non-Preferred Brand Drugs

35.00% Coinsurance after deductible
Tier 1 in-network 35.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Preferred Brand Drugs

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 35.00% Coinsurance after deductible
Out-of-network 100.00%

Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Specialty Drugs

45.00% Coinsurance after deductible
Tier 1 in-network 45.00% Coinsurance after deductible
Tier 2 in-network 45.00% Coinsurance after deductible
Out-of-network 100.00%

Certain specialty drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

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

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

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Covered when medically necessary

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

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

nan

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

When services are provided in an office setting, cost shares may vary. Please see benefit booklet for details.

Exclusions: nan

Bariatric Surgery

Coverage details pending

nan

Exclusions: nan

Cosmetic Surgery

Coverage details pending

Except when medically necessary.

Exclusions: nan

Eye Glasses for Children

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

Limit: 1.0 Item(s) per Benefit Period

All frames will first apply towards the allowance. Discount will apply on remaining balance, after the allowance. See benefit book for details

Exclusions: nan

Gender Affirming Care

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Habilitation Services

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

Limit: 25.0 Visit(s) per Benefit Period

Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

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

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 85.0 Visit(s) per Benefit Period

nan

Exclusions: nan

Reconstructive Surgery

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

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.

Exclusions: nan

Routine Eye Exam (Adult)

Coverage details pending

nan

Exclusions: nan

Routine Foot Care

Coverage details pending

Covered when medically necessary

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

Coverage details pending

nan

Exclusions: nan

Variant attributes

MyBlue Bronze HMO℠ 904 · Variant 87571OK0510085-00

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Standard Bronze Off Exchange Plan

HIOS Product ID

87571OK051

Metal Level

Bronze

Plan ID (Standard Component ID with Variant)

87571OK0510085-00

Plan Marketing Name

MyBlue Bronze HMO℠ 904

Plan Variant Marketing Name

MyBlue Bronze HMO℠ 904

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

87571

Issuer Marketplace Marketing Name

Blue Cross and Blue Shield of Oklahoma

Market Coverage

Individual

Multiple In Network Tiers

Yes

National Network

No

Network ID

OKN002

Out of Country Coverage

Yes

Out of Country Coverage Description

This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs.

Out of Service Area Coverage

Yes

Out of Service Area Coverage Description

Coverage outside our service area is available for Emergency and Urgent Care services only.

Service Area ID

OKS042

State Code

OK

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.617647677620141

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

$3,100

SBC Scenario, Having a Baby, Copayment

$400

SBC Scenario, Having a Baby, Deductible

$4,500

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$800

SBC Scenario, Having Diabetes, Deductible

$1,600

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$0

SBC Scenario, Treatment of a Simple Fracture, Copayment

$600

SBC Scenario, Treatment of a Simple Fracture, Deductible

$2,100

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, In Network (Tier 1), Default Coinsurance

40.00%

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

40.00%

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

$18400 per group

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

$9200 per person

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

$9,200

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

$18400 per group

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

$9200 per person

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

$9,200

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

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

OKF010

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

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

85%

Import Date

2025-01-11 00:01:52

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

New

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

Yes

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

HMO

QHP/Non QHP

Both

Second Tier Utilization

15%

Source Name

HIOS

Specialist Requiring a Referral

Referrals are required for some services. Please check with your Medical Group for details.

Plan ID

87571OK0510085

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), Family Per Group

$9000 per group

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

$4500 per person

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

$4,500

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

$9000 per group

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

$4500 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual

$4,500

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

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 Oklahoma?

MyBlue Bronze HMO℠ 904 (87571OK0510085) is a Bronze HMO from Blue Cross Blue Shield of Oklahoma in Oklahoma 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 MyBlue Bronze HMO℠ 904 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 MyBlue Bronze HMO℠ 904 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 MyBlue Bronze HMO℠ 904 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 MyBlue Bronze HMO℠ 904?

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 MyBlue Bronze HMO℠ 904?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs.

Does MyBlue Bronze HMO℠ 904 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: Coverage outside our service area is available for Emergency and Urgent Care 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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