Plan Details

87698OK0110029-00

Plan Year:

2023

Gold Metal plans cover an estimated 80% of your medical and prescription drug costs. They also limit your annual out-of-pocket expenses.

Individual Deductible:	$2,500
Individual Out of Pocket Maximum:	$5,000
Office Visit Copay:	$35
Out of Network Coinsurance:	30%^*
Preferred Generics:	$15
Preferred Brand Name:	$45
Non-Preferred Brand Name:	$95^*
Individual Rx Deductible:	Integrated
Preferred Specialty:	$300^*
Non-Preferred Specialty:	$350^*
OON Individual Deductible:	$4,000
OON Family Deductible:	$12,000
OON OOP Individual Deductible:	Unlimited
OON OOP Family Deductible:	Unlimited
OON Office Visit Copay:	30%^†
Specialist Copay:	$55
OON Specialist Copay:	30%^†
Coinsurance:	0%^*

^*Subject to the deductible.

^†First 3 primary care visits have a $35 co-payment and are not subject to the deductible.

Benefit Details

All health plans in the exchanges are required to provide a minimum set of benefits which are termed essential benefits. These benefits include: