Friday Standard Silver

90617GA0010025
Silver
HMO

Friday Standard Silver is a Silver HMO plan by Friday Health Plans of Georgia Inc.

IMPORTANT: You are viewing the 2023 version of Friday Standard Silver 90617GA0010025. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Friday Standard Silver is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Friday Standard Silver 90617GA0010025.
Insurer: Friday Health Plans of Georgia Inc
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 90617GA0010025

Cost-Sharing Overview

Friday Standard Silver offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Friday Standard Silver?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Friday Standard Silver offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Diabetes, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Friday Standard Silver covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Urgent and Emergent
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Urgent and Emergent
National Network: No

Additional Benefits and Cost-Sharing

Friday Standard Silver includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 100.00%
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
40.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$60.00 $60.00
Home Health Care Services
Covered
40.00% Coinsurance after deductible 100.00%120 Visit(s) per Year
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Covered
40.00% Coinsurance after deductible 100.00%
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 100.00%60 Days per Year
Prenatal and Postnatal Care
Covered
$80.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$20.00 100.00% Value displayed reflects the maximum copay / co insurance amount a member could pay.
Preferred Brand Drugs
Covered
$40.00 100.00% Value displayed reflects the maximum copay / co insurance amount a member could pay.
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00% Value displayed reflects the maximum copay / co insurance amount a member could pay.
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00% Value displayed reflects the maximum copay / co insurance amount a member could pay.
Outpatient Rehabilitation Services
Covered
$40.00 100.00%40 Visit(s) per Year Limited to 40 PT/OY/ST rehabilitation visits per plan year
Habilitation Services
Covered
$40.00 100.00%40 Visit(s) per Year Limited to 40 PT/OT/ST Habilitation outpatient visits per therapy per plan year
Chiropractic Care
Covered
40.00% Coinsurance after deductible 100.00% Limited to 40 visits per plan year
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
40.00% Coinsurance after deductible 100.00% Limit of one hearing aid per year, every 48 months.
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).
Routine Foot Care
Acupuncture
Weight Loss Programs
Covered
$80.00 100.00%
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
2 Procedure(s) per Year
Rehabilitative Speech Therapy
Covered
$40.00 100.00%40 Visit(s) per Year Limited to 40 PT/OY/ST rehabilitation visits per plan year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 100.00%40 Visit(s) per Year Limited to 40 PT/OY/ST rehabilitation visits per plan year
Well Baby Visits and Care
Covered
No Charge 100.00% Care provided for birth through age 5.
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
40.00% Coinsurance after deductible 100.00%10000 Dollars per Procedure Limited to a combined maximum of $10,000 per covered organ transplant.
Accidental Dental
Covered
40.00% Coinsurance after deductible 100.00%
Dialysis
Covered
40.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
40.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00%
Radiation
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
No Charge 100.00%
Prosthetic Devices
Covered
40.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
40.00% Coinsurance after deductible 100.00% Insulin infusion devices.
Treatment for Temporomandibular Joint Disorders
Covered
40.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
$40.00 100.00%4 Visit(s) per Year
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
40.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Friday Standard Silver preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Friday Standard Silver including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Friday Standard Silver?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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