Plan Details

87698OK0110040-00

Plan Year:

2023

Silver Metal plans cover an estimated 70% of your medical and prescription drug costs. They limit your annual out-of-pocket expenses.

Individual Deductible:	$5,500
Individual Out of Pocket Maximum:	$8,900
Office Visit Copay:	$30
Out of Network Coinsurance:	30%^*
Preferred Generics:	$15
Preferred Brand Name:	$45
Non-Preferred Brand Name:	$95
Individual Rx Deductible:	None
Preferred Specialty:	$300
Non-Preferred Specialty:	$350
OON Individual Deductible:	$10,000
OON Family Deductible:	$30,000
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.

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: