Plan Details

87698OK0110042-00

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:	$2,000
Individual Out of Pocket Maximum:	$8,500
Office Visit Copay:	$25
Out of Network Coinsurance:	50%^*
Preferred Generics:	$15
Preferred Brand Name:	$40
Non-Preferred Brand Name:	$70
Individual Rx Deductible:	None
Preferred Specialty:	$160
Non-Preferred Specialty:	$210
OON Individual Deductible:	$4,000
OON Family Deductible:	$12,000
OON OOP Individual Deductible:	Unlimited
OON OOP Family Deductible:	Unlimited
OON Office Visit Copay:	50%^*
Specialist Copay:	$35
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: