Standard Silver - 62505OK0120020 Health Insurance Plan

Celtic Insurance Company health insurance plan with the Plan ID 62505OK0120020. The plan is called Standard Silver.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.03% (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 12.97% 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 62505OK0120020
Health Insurance Plan Year 2024
State Oklahoma
Health Insurance Issuer Celtic Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 62505OK0120020-05
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT).

Providers Oklahoma All US States
All N/A 1
PCP N/A 1
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 - 62505OK0120020-00

Standard On Exchange Plan - 62505OK0120020-01

Open to Indians below 300% FPL - 62505OK0120020-02

Open to Indians above 300% FPL - 62505OK0120020-03

73% AV Silver Plan - 62505OK0120020-04

87% AV Silver Plan - 62505OK0120020-05

94% AV Silver Plan - 62505OK0120020-06

Last Plan Update Date Sat, 16 Dec 2023 00:00 GMT
Last Import Date Tue, 22 Oct 2024 06:47 GMT

Benefits of Standard Silver Health Insurance Plan, 62505OK0120020-05

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

$40.00

60.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Chiropractic Care
YES

$40.00

60.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Education
YES

$40.00

60.00% Coinsurance after deductible
Dialysis
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Durable Medical Equipment
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Emergency Room Services
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

OON: Up to $50 for frames, $37.50 for lenses and $91 for contacts in lieu of eyeglasses. See EOC for lens limits.

YES

No Charge

No Charge
Gender Affirming Care
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Generic Drugs

Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.

YES

$10.00

100.00%
Habilitation Services

Limit: 25.0 Visit(s) per Year

Per year, limited to 25 visits combined (occupational, speech and physical therapy). Inpatient habilitation services limited to 30 days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

YES

$20.00

60.00% Coinsurance after deductible
Hearing Aids

Limit: 2.0 Item(s) per Benefit Period

One hearing aid per ear every 4 years.

YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Home Health Care Services

Limit: 30.0 Visit(s) per Year

YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Hospice Services

Exclusions: Excludes respite care.

YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Infertility Treatment

Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).

NO
Infusion Therapy

Limit: 25.0 Visit(s) per Year

YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care

Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit.

NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Emergency Room
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Other Services
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

YES

$20.00

60.00% Coinsurance after deductible
Mental/Behavioral Health Urgent Care
YES

$30.00

60.00%
Non-Preferred Brand Drugs
YES

$60.00 Copay after deductible

100.00%
Nutritional Counseling
YES

$40.00

60.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$20.00

60.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 25.0 Visit(s) per Year

Per year, limited to 25 visits combined (occupational, speech and physical therapy). Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

YES

$20.00

60.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Preferred Brand Drugs
YES

$20.00

100.00%
Prenatal and Postnatal Care
YES

$20.00

60.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

0.00%

60.00%
Primary Care Visit to Treat an Injury or Illness
YES

$20.00

60.00% Coinsurance after deductible
Private-Duty Nursing

Limit: 85.0 Visit(s) per Year

YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Prosthetic Devices
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Radiation
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Reconstructive Surgery

1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality... 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card.

YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 25.0 Visit(s) per Year

Maximum of 25 outpatient visits for physical therapy, occupational therapy and speech therapy (combined). Inpatient rehabilitation limited to 30 days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

YES

$20.00

60.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 25.0 Visit(s) per Year

Maximum of 25 outpatient visits for physical therapy, occupational therapy and speech therapy (combined). Inpatient rehabilitation limited to 30 days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

YES

$20.00

60.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

Up to $38.50 OON

YES

No Charge

No Charge
Routine Foot Care
YES

$40.00

60.00% Coinsurance after deductible
Skilled Nursing Facility

Limit: 30.0 Days per Year

YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Specialist Visit
YES

$40.00

60.00% Coinsurance after deductible
Specialty Drugs
YES

$250.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services

Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

YES

$20.00

60.00% Coinsurance after deductible
Substance Use Disorder Emergency Room
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Substance Use Disorder Emergency Transportation/Ambulance
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Substance Use Disorder Outpatient Other Services
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Substance Use Disorder Urgent Care
YES

$30.00

60.00%
Transplant

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.

YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Urgent Care Centers or Facilities
YES

$30.00

60.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

60.00%
X-rays and Diagnostic Imaging
YES

30.00% Coinsurance after deductible

60.00% Coinsurance after deductible

Standard Silver Health Insurance Plan Variant 62505OK0120020-05 Attributes

Plan Attribute Value
AV Calculator Output Number 0.87028256655624
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2024
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 Design 1
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID OKF010
Formulary URL URL
HIOS Product ID 62505OK012
Import Date 2023-12-16 01:02:09
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 Yes
Is a Referral Required for Specialist? No
Issuer ID 62505
Issuer Marketplace Marketing Name Ambetter of Oklahoma
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 No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan ID (Standard Component ID with Variant) 62505OK0120020-05
Plan Marketing Name Standard Silver
Plan Type PPO
Plan Variant Marketing Name Standard Silver
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,300
SBC Scenario, Having a Baby, Copayment $20
SBC Scenario, Having a Baby, Deductible $700
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $60
SBC Scenario, Having Diabetes, Copayment $600
SBC Scenario, Having Diabetes, Deductible $700
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $400
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OKS001
Source Name HIOS
Plan ID 62505OK0120020
State Code OK
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 $6200 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $3100 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $3,100
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 $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 $4800 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $2400 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $2,400
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $6000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $3000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $3,000
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 Standard Silver Health Insurance Plan, 62505OK0120020

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

Frequently Asked Questions(FAQ) about Standard Silver, 62505OK0120020 Health Insurance Plan, 62505OK0120020

  • Does Standard Silver Health Insurance Plan, 62505OK0120020 support Mail Ordering?

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

  • Does (62505OK0120020) Health Insurance Plan, Variant (62505OK0120020-05) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (62505OK0120020) Health Insurance Plan, Variant (62505OK0120020-05) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (62505OK0120020) Health Insurance Plan, Variant (62505OK0120020-05) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (62505OK0120020) Health Insurance Plan, Variant (62505OK0120020-05) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does Standard Silver Health Insurance Plan, Variant (62505OK0120020-05) offer Disease Management Programs for Asthma?

    Yes, the Standard Silver Health Insurance Plan Variant 62505OK0120020-05 offers Disease Management Program for Asthma.

    Does Standard Silver Health Insurance Plan, Variant (62505OK0120020-05) offer Disease Management Programs for Heart disease?

    Yes, the Standard Silver Health Insurance Plan Variant 62505OK0120020-05 offers Disease Management Program for Heart disease.

    Does Standard Silver Health Insurance Plan, Variant (62505OK0120020-05) offer Disease Management Programs for Diabetes?

    Yes, the Standard Silver Health Insurance Plan Variant 62505OK0120020-05 offers Disease Management Program for Diabetes.

    Does Standard Silver Health Insurance Plan, Variant (62505OK0120020-05) offer Disease Management Programs for Pregnancy?

    Yes, the Standard Silver Health Insurance Plan Variant 62505OK0120020-05 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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