Plan Details

87698OK0110043-00

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:	$8,225
Individual Out of Pocket Maximum:	$8,225
Office Visit Copay:	$25
Out of Network Coinsurance:	30%^*
Preferred Generics:	$0
Preferred Brand Name:	$0^*
Non-Preferred Brand Name:	$0^*
Individual Rx Deductible:	Integrated
Preferred Specialty:	$0^*
Non-Preferred Specialty:	$0^*
OON Individual Deductible:	$17,400
OON Family Deductible:	$35,800
OON OOP Individual Deductible:	Unlimited
OON OOP Family Deductible:	Unlimited
OON Office Visit Copay:	30%^*
Specialist Copay:	$50
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: