Silver Classic - 77739MI0070006 Health Insurance Plan
Oscar Insurance Company health insurance plan with the Plan ID 77739MI0070006. The plan is called Silver Classic.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.07% (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 12.93% 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 | 77739MI0070006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Oscar Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 77739MI0070006-05 | ||||||||||||||||||
| Provider Network(s) | ['MIN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 77739MI0070006-00 Standard On Exchange Plan - 77739MI0070006-01 Open to Indians below 300% FPL - 77739MI0070006-02 Open to Indians above 300% FPL - 77739MI0070006-03 73% AV Silver Plan - 77739MI0070006-04 |
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| Last Plan Update Date | Tue, 28 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
Benefits of Silver Classic Health Insurance Plan, 77739MI0070006-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $40.00 |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime |
YES | 30.00% |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 30.00% |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Limit combined with OT and PT. |
YES | $40.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 30.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00 |
100.00% |
| Dialysis
|
YES | 30.00% |
100.00% |
| Durable Medical Equipment
|
YES | 30.00% |
100.00% |
| Emergency Room Services
|
YES | $750.00 |
$750.00 |
| Emergency Transportation/Ambulance
|
YES | $750.00 |
$750.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
YES | 30.00% |
100.00% |
| Generic Drugs
Oscar is on a mission to make your prescriptions more affordable. That?s why your savings start on day 1 of your new plan. All Oscar members have access to 24/7 virtual urgent care services. Depending on your plan, if your Oscar Virtual Urgent Care provider prescribes any prescriptions on the Generics: Tier 1a or Generics: Tier 1b list during your visit, those prescriptions will be free.* Generics: Tier 1a: Drugs on this list will never cost you more than $3, no matter who prescribes them. Check to see if your prescriptions are on the $3 Prescription List at https://www.hioscar.com/prescriptions/3-dollar-list Prescriptions included in Generics: Tier 1b will always cost you less than $30, no matter who prescribes them?even if you haven?t hit your deductible. Find out which Tiers the drugs you take are on at www.hioscar.com/search *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan. Virtual visits with other providers in Oscar?s network will not be free and the additional savings will not apply. |
YES | Tier 1: $3.00 Tier 2: $20.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits. |
YES | $40.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | $40.00 |
100.00% |
| Hospice Services
Coverage includes inpatient and outpatient hospice care. |
YES | 30.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% |
100.00% |
| Infertility Treatment
Underlying causes only. |
YES | 30.00% |
100.00% |
| Infusion Therapy
|
YES | 30.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: $10.00 Tier 2: $25.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 30.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $40.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% |
100.00% |
| Nutritional Counseling
Limit: 6.0 Visit(s) per Year Dietician Services. |
YES | $10.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $10.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year PT/OT/Chiro - combined visits per contract year; 30 ST per contract year; 30 cardiac/pulmonary visits per contract year. |
YES | $40.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% |
100.00% |
| Preferred Brand Drugs
|
YES | $75.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $0.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00 |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Virtual visits with an Oscar Care urgent care provider are unlimited and always $0?even if you haven?t hit your deductible. Depending on your plan, many prescriptions and labs will also cost you $0, if they?re ordered by your Oscar Virtual Urgent Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan. |
YES | $10.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 30.00% |
100.00% |
| Radiation
|
YES | 30.00% |
100.00% |
| Reconstructive Surgery
|
YES | 30.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Combined with chiro. |
YES | $40.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | $40.00 |
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 | $0.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year |
YES | 30.00% |
100.00% |
| Specialist Visit
|
YES | $40.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 30.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $40.00 |
100.00% |
| Transplant
|
YES | 30.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Coverage includes medical care or services to treat dysfunction or TMJS resulting from a medical cause or injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental X-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis. |
YES | 30.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $40.00 |
100.00% |
| Weight Loss Programs
|
YES | 100.00% | |
| Well Baby Visits and Care
|
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $50.00 |
100.00% |
Silver Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 77739MI0070006-05 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.870670035 |
| 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 | 87% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 20% |
| Formulary ID | MIF001 |
| Formulary URL | URL |
| HIOS Product ID | 77739MI007 |
| Import Date | 2/28/2023 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 77739 |
| Issuer Marketplace Marketing Name | Oscar Insurance Company |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | MIN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency and Urgent Services only |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 77739MI0070006-05 |
| Plan Marketing Name | Silver Classic |
| Plan Type | EPO |
| Plan Variant Marketing Name | Silver Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,700 |
| SBC Scenario, Having a Baby, Copayment | $200 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,800 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 80% |
| Service Area ID | MIS001 |
| Source Name | SERFF |
| Plan ID | 77739MI0070006 |
| State Code | MI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | 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 | $5800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $2900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $2,900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $5800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $2900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $2,900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Silver Classic Health Insurance Plan, 77739MI0070006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver Classic, 77739MI0070006 Health Insurance Plan, 77739MI0070006
-
Does Silver Classic Health Insurance Plan, 77739MI0070006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (77739MI0070006) Health Insurance Plan, Variant (77739MI0070006-05) offer Disease Management Programs?
Does (77739MI0070006) Health Insurance Plan, Variant (77739MI0070006-05) have Out Of Country Coverage?
Does (77739MI0070006) Health Insurance Plan, Variant (77739MI0070006-05) have Out of Service Area Coverage?
Does (77739MI0070006) Health Insurance Plan, Variant (77739MI0070006-05) offer Disease Management Programs?
Does Silver Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (77739MI0070006-05) offer Disease Management Programs for Asthma?
Does Silver Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (77739MI0070006-05) offer Disease Management Programs for Heart disease?
Does Silver Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (77739MI0070006-05) offer Disease Management Programs for Depression?
Does Silver Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (77739MI0070006-05) offer Disease Management Programs for Diabetes?
Does Silver Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (77739MI0070006-05) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Silver Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (77739MI0070006-05) offer Disease Management Programs for Low back pain?
Does Silver Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (77739MI0070006-05) offer Disease Management Programs for Pregnancy?
Does Silver Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (77739MI0070006-05) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 01 Oct 2024 06:11 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