Plan Details

87698OK0110041-00

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:	$3,800
Individual Out of Pocket Maximum:	$7,000
Office Visit Copay:	$15^*
Out of Network Coinsurance:	50%^*
Preferred Generics:	$15^*
Preferred Brand Name:	$40^*
Non-Preferred Brand Name:	$70^*
Individual Rx Deductible:	Integrated
Preferred Specialty:	$160^*
Non-Preferred Specialty:	$210^*
OON Individual Deductible:	$7,600
OON Family Deductible:	$22,800
OON OOP Individual Deductible:	Unlimited
OON OOP Family Deductible:	Unlimited
OON Office Visit Copay:	50%^*
Specialist Copay:	$30^*
OON Specialist Copay:	50%^*
Coinsurance:	20%^*

^*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: