TARO Direct Primary Care Gold $0 Ded ($0 DPC + $0 PCP + $0 Mental Health) - 58944OK0010006 Health Insurance Plan

Taro Health Plan of Oklahoma, Inc. health insurance plan with the Plan ID 58944OK0010006. The plan is called TARO Direct Primary Care Gold $0 Ded ($0 DPC + $0 PCP + $0 Mental Health).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.80% (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 18.20% 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 58944OK0010006
Health Insurance Plan Year 2025
State Oklahoma
Health Insurance Issuer Taro Health Plan of Oklahoma, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 58944OK0010006-00
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Oklahoma All US States
All 14798 15861
PCP 2194 2370
Allergy 9 10
OB/GYN 66 71
Dentists 25 25
Available Variants of the Health Plan

Standard Off Exchange Plan - 58944OK0010006-00

Standard On Exchange Plan - 58944OK0010006-01

Open to Indians below 300% FPL - 58944OK0010006-02

Open to Indians above 300% FPL - 58944OK0010006-03

Last Plan Update Date Tue, 22 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of TARO Direct Primary Care Gold $0 Ded ($0 DPC + $0 PCP + $0 Mental Health) Health Insurance Plan, 58944OK0010006-00

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

50.00%

100.00%
Acupuncture
NO
Allergy Testing

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

YES

$35.00

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

50.00%

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Benefit Period

Chiropractic Care limit is combined with Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

YES

$30.00

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

50.00%

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

50.00%

100.00%
Durable Medical Equipment

Prior authorization may be required.

YES

50.00%

100.00%
Emergency Room Services
YES

50.00%

50.00%
Emergency Transportation/Ambulance

Services are only covered if medically necessary

YES

50.00%

50.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

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

YES

$15.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

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

YES

$30.00

100.00%
Hearing Aids

One hearing aid per ear every 48 months

YES

50.00%

100.00%
Home Health Care Services

Limit: 30.0 Visit(s) per Benefit Period

YES

50.00%

100.00%
Hospice Services

Prior authorization required.

YES

50.00%

100.00%
Imaging (CT/PET Scans, MRIs)

Prior authorization may be required.

YES

50.00%

100.00%
Infertility Treatment

We may cover Standard Fertility Preservation Services, for individuals diagnosed with cancer and who are within Reproductive Age, when a medically necessary treatment may directly or indirectly cause Iatrogenic Infertility.

NO
Infusion Therapy

Limit: 25.0 Visit(s) per Benefit Period

Covered under Outpatient Therapy Services.

YES

50.00%

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

Prior authorization may be required.

YES

50.00%

100.00%
Inpatient Physician and Surgical Services

Prior authorization may be required.

YES

50.00%

100.00%
Laboratory Outpatient and Professional Services
YES

50.00%

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

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

YES

50.00%

100.00%
Mental/Behavioral Health Outpatient Services

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

YES

No Charge

100.00%
Non-Preferred Brand Drugs

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

YES

$100.00

100.00%
Nutritional Counseling

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

YES

No Charge

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

No Charge

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

Prior authorization may be required.

YES

50.00%

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Days per Benefit Period

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

YES

$30.00

100.00%
Outpatient Surgery Physician/Surgical Services

Prior authorization may be required.

YES

50.00%

100.00%
Preferred Brand Drugs

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

YES

$50.00

100.00%
Prenatal and Postnatal Care
YES

$35.00

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

No Charge

100.00%
Private-Duty Nursing

Limit: 85.0 Visit(s) per Benefit Period

Prior authorization required.

YES

50.00%

100.00%
Prosthetic Devices

Prior authorization may be required

YES

50.00%

100.00%
Radiation
YES

50.00%

100.00%
Reconstructive Surgery

Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary.

YES

50.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Benefit Period

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

YES

$30.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Benefit Period

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

YES

$30.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

One eye exam every 12 months from last date of service.

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Benefit Period

Prior authorization required.

YES

50.00%

100.00%
Specialist Visit
YES

$35.00

100.00%
Specialty Drugs

Up to 30-day supply Retail only.

YES

$200.00

100.00%
Substance Abuse Disorder Inpatient Services

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

YES

50.00%

100.00%
Substance Abuse Disorder Outpatient Services

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

YES

No Charge

100.00%
Transplant
YES

50.00%

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

$100.00

$100.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

50.00%

100.00%

TARO Direct Primary Care Gold $0 Ded ($0 DPC + $0 PCP + $0 Mental Health) Health Insurance Plan Variant 58944OK0010006-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.8180253424469199
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID OKF005
Formulary URL URL
HIOS Product ID 58944OK001
Import Date 2024-10-22 01:01:28
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 58944
Issuer Marketplace Marketing Name Taro Health Plan
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID OKN001
Out of Country Coverage No
Out of Service Area Coverage No
Out of Service Area Coverage Description Emergency Services Only
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 58944OK0010006-00
Plan Marketing Name TARO Direct Primary Care Gold $0 Ded ($0 DPC + $0 PCP + $0 Mental Health)
Plan Type HMO
Plan Variant Marketing Name TARO Direct Primary Care Gold $0 Ded ($0 DPC + $0 PCP + $0 Mental Health)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $6,300
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $500
SBC Scenario, Having Diabetes, Copayment $600
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $1,000
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OKS001
Source Name HIOS
Plan ID 58944OK0010006
State Code OK
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $15600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $7800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $7,800
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
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, 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 $15600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,800
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 TARO Direct Primary Care Gold $0 Ded ($0 DPC + $0 PCP + $0 Mental Health) Health Insurance Plan, 58944OK0010006

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

Frequently Asked Questions(FAQ) about TARO Direct Primary Care Gold $0 Ded ($0 DPC + $0 PCP + $0 Mental Health), 58944OK0010006 Health Insurance Plan, 58944OK0010006

  • Does TARO Direct Primary Care Gold $0 Ded ($0 DPC + $0 PCP + $0 Mental Health) Health Insurance Plan, 58944OK0010006 support Mail Ordering?

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

  • Does (58944OK0010006) Health Insurance Plan, Variant (58944OK0010006-00) have Out Of Country Coverage?

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

    Does (58944OK0010006) Health Insurance Plan, Variant (58944OK0010006-00) have Out of Service Area Coverage?

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

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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