MyBlue Silver HMO℠ Standard
87571OK0510099
Silver
HMO
MyBlue Silver HMO℠ Standard is a Silver HMO plan by Blue Cross and Blue Shield of Oklahoma.
Locations
MyBlue Silver HMO℠ Standard is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of MyBlue Silver HMO℠ Standard 87571OK0510099.
| Insurer: | Blue Cross and Blue Shield of Oklahoma |
| Network Type: | HMO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 87571OK0510099 |
Cost-Sharing Overview
MyBlue Silver HMO℠ Standard offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for MyBlue Silver HMO℠ Standard includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8000 per person | $16000 per group |
| Deductible: | $5000 per person | $10000 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for MyBlue Silver HMO℠ Standard will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $5,000 |
| Copayment: | $0 |
| Coinsurance: | $3,000 |
| Limit: | $60 |
| Deductible: | $900 |
| Copayment: | $1,000 |
| Coinsurance: | $0 |
| Limit: | $20 |
| Deductible: | $2,100 |
| Copayment: | $400 |
| Coinsurance: | $0 |
| Limit: | $0 |
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 MyBlue Silver HMO℠ Standard?
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
MyBlue Silver HMO℠ Standard offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| Notice Pregnancy: | No |
| Referral Specialist: | Yes |
| Specialist Requiring Referral: | Referrals are required for some services. Please check with your Medical Group for details. |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what MyBlue Silver HMO℠ Standard covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs. |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Coverage outside our service area is available for Emergency and Urgent Care services only. |
| National Network: | No |
Additional Benefits and Cost-Sharing
MyBlue Silver HMO℠ Standard 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 Not Applicable | Not Applicable 100.00% | |
| Specialist Visit Covered | $80.00 Not Applicable | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $80.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 85.0 Visit(s) per Benefit Period |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $60.00 Not Applicable | Not Applicable 100.00% | |
| Home Health Care Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 30.0 Visit(s) per Benefit Period |
| Emergency Room Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | Except when medically necessary. | ||
| Skilled Nursing Facility Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 30.0 Days per Benefit Period |
| Prenatal and Postnatal Care Covered | $40.00 Not Applicable | Not Applicable 100.00% | First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care. |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable. |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | Member cost share may increase when using a setting other than office. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Member cost share may increase when using a setting other than office. |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | Member cost share may increase when using a setting other than office. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Member cost share may increase when using a setting other than office. |
| Generic Drugs Covered | $20.00 Not Applicable | Not Applicable 100.00% | Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. Certain generic drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details. |
| Preferred Brand Drugs Covered | $40.00 Not Applicable | Not Applicable 100.00% | Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. |
| Non-Preferred Brand Drugs Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. |
| Specialty Drugs Covered | $350.00 Copay after deductible Not Applicable | Not Applicable 100.00% | Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. Certain specialty drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. |
| Outpatient Rehabilitation Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | 25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
| Habilitation Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | 25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
| Chiropractic Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
| Durable Medical Equipment Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hearing Aids Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 1 hearing aid per ear (2 hearing aids) every 48 months for any covered member. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 100.00% | |
| Routine Foot Care Not Covered | Covered when medically necessary | ||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Visit(s) per Benefit Period When purchasing Out of Network, reimbursements are available. See benefit book for details |
| Eye Glasses for Children Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Item(s) per Benefit Period All frames will first apply towards the allowance. Discount will apply on remaining balance, after the allowance. See benefit book for details |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $40.00 Not Applicable | Not Applicable 100.00% | 25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $40.00 Not Applicable | Not Applicable 100.00% | 25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations. |
| Well Baby Visits and Care Covered | No Charge Not Applicable | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
| X-rays and Diagnostic Imaging Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult Not Covered | |||
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Not Covered | |||
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Accidental Dental Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Dialysis Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Allergy Testing Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | When services are provided in an office setting, cost shares may vary. Please see benefit booklet for details. |
| Chemotherapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Education Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Prosthetic Devices Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Infusion Therapy Covered | $100.00 Not Applicable | Not Applicable 100.00% | Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
| Treatment for Temporomandibular Joint Disorders Not Covered | |||
| Nutritional Counseling Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Covered when medically necessary |
| Reconstructive Surgery Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary. |
| Gender Affirming Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% |
Free Preventive Services
There is no copayment or coinsurance for any of the following MyBlue Silver HMO℠ Standard 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for MyBlue Silver HMO℠ Standard 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 MyBlue Silver HMO℠ Standard?
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