MyBlue Silver HMO℠ Standard

Health Insurance Plan Details (2025 Plan)

by Blue Cross Blue Shield of Oklahoma

Monthly Premium

HMO
$ubsidy
Silver
Deductible
$5,000 /yr
Max Out-of-Pocket
$8,000 /yr

Details

Deductible (per individual) $5,000 /yr
Deductible (per family) $10,000 /yr
Max Out-of-Pocket (per individual) $8,000 /yr
Max Out-of-Pocket (per family) $16,000 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $40 Copay
Specialist Visit $80 Copay
Emergency Room 40% Coinsurance after deductible
Inpatient Facility 40% Coinsurance after deductible
Inpatient Physician 40% Coinsurance after deductible
Drug Costs
Generic Drugs $20 Copay
Preferred Brand Drugs $40 Copay
Non-preferred Brand Drugs $80 Copay after deductible
Specialty Drugs $350 Copay after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

Insurance Carrier Disclaimer

Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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