OptimaFit Silver 5800 40% Standard M

20507VA1410069
Silver
HMO

OptimaFit Silver 5800 40% Standard M is a Silver HMO plan by Optima Health.

IMPORTANT: You are viewing the 2023 version of OptimaFit Silver 5800 40% Standard M 20507VA1410069. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

OptimaFit Silver 5800 40% Standard M is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of OptimaFit Silver 5800 40% Standard M 20507VA1410069.
Insurer: Optima Health
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 20507VA1410069

Cost-Sharing Overview

OptimaFit Silver 5800 40% Standard M 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 OptimaFit Silver 5800 40% Standard M?

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

OptimaFit Silver 5800 40% Standard M offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, 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 OptimaFit Silver 5800 40% Standard M covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Only
National Network: No

Additional Benefits and Cost-Sharing

OptimaFit Silver 5800 40% Standard M 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% Applies to Covered Services done during an office visit, including doctor visits in the home and online visits. You will pay an additional Copayment or Coinsurance for outpatient Habilitative and Rehabilitative therapy and services, injectable and infused medications, allergy care, testing and serum, outpatient advanced imaging procedures, and sleep studies done during an office visit. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
40.00% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 100.00% Copayment or Coinsurance applies to services provided in a free-standing ambulatory surgery center or Hospital outpatient surgical facility. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00% Include professional services received while receiving covered services in a free-standing outpatient facility, or a hospital outpatient facility. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
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
Covered
40.00% Coinsurance after deductible 100.00%16 Hours per Benefit Period 16 Hours per Benefit Period. The Plan will not cover any additional services after the limits have been reached.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 100.00%
Home Health Care Services
Covered
40.00% Coinsurance after deductible 100.00%100 Visit(s) per Benefit Period 100 Visits per Benefit Period. The Plan will not cover any additional services after the limits have been reached.
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible Covered Services include diagnostic x-ray, lab services, medical supplies, and advanced diagnostic imaging, such as MRIs and CT scans to evaluate and Stabilize a patient with an Emergency Medical Condition. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
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% Include surgery and services received during an inpatient stay that are required to treat medical condition, illness, or injury. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
Inpatient Physician and Surgical Services
Covered
40.00% Coinsurance after deductible 100.00% Include professional services received while receiving covered services in an inpatient hospital. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 100.00%100 Days per Stay Following inpatient Hospital care or in lieu of hospitalization when, in the Plan?s judgment, skilled services are required. Services include up to 100 days per stay. The Plan will not cover any additional services after the limits have been reached. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
Prenatal and Postnatal Care
Covered
40.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 100.00% This plan contracts with birthing centers.
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00% Include covered services provided in an office based setting or other outpatient facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details regarding mental health and substance use disorder Other Oupatient Services.
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00% Include covered services provided in an inpatient facility or substance use disorder treatment facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00% Include covered services provided in an office based setting or other outpatient facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details regarding mental health and substance use disorder Other Oupatient Services.
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00% Include covered services provided in an inpatient facility or substance use disorder treatment facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
Generic Drugs
Covered
$20.00 100.00% Include commonly prescribed generic drugs. Other drugs may be included in Tier 1 if the Plan recognizes they show documented long-term decreases in illness. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Preferred Brand Drugs
Covered
$40.00 100.00% Include brand-name drugs and some generic drugs with higher costs than Tier 1 generics that are considered by the Plan to be standard therapy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00% Include brand name drugs not included by the Plan on Tier 1 or Tier 2. These may include single source brand name drugs that do not have a generic equivalent or a therapeutic equivalent. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00% Include those drugs classified by the Plan as Specialty Drugs and compound prescription medications. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Outpatient Rehabilitation Services
Covered
40.00% Coinsurance after deductible 100.00% Visit limits may apply. See individual therapy limits. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Habilitation Services
Covered
40.00% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period Include services and devices that help a member keep, learn or improve skills and functioning for daily living, and other services for people with disabilities in a variety of inpatient and outpatient settings or facilities. Visit limits may apply. See individual therapy limits. The Plan will not cover any additional services after the limits have been reached. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
Chiropractic Care
Covered
40.00% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period 30 Visits per Benefit Period. Limit applies separately to habilitative and rehabilitative services. The Plan will not cover any additional services after the limits have been reached.
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00%
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge No Charge 100.00%1 Exam(s) per Benefit Period Includes one exam per benefit period. The Plan will not cover any additional services after the limits have been reached. Low vision exams are limited to one every 5 years. Exams must be received from participating providers. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
Eye Glasses for Children
Covered
No Charge No Charge 100.00%1 Item(s) per Benefit Period Includes one pair of standard single vision, bifocal, trifocal, or progressive eyeglass lenses and one frame per benefit period. This Plan only covers a choice of contact lenses or eyeglasses, but not both. The Plan will not cover any additional services after the limits have been reached. Materials must be received from participating providers. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 100.00%30 Visit(s) per Benefit Period 30 Visits per Benefit Period. Limit applies separately to habilitative and rehabilitative services. The Plan will not cover any additional services after the limits have been reached. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 100.00%30 Visit(s) per Benefit Period 30 Visits per Benefit Period. Limit applies separately to habilitative and rehabilitative services. The Plan will not cover any additional services after the limits have been reached. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%
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%
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 No Charge 100.00%
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
40.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
40.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
40.00% Coinsurance after deductible 100.00%
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00%
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following OptimaFit Silver 5800 40% Standard M 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 OptimaFit Silver 5800 40% Standard M 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 OptimaFit Silver 5800 40% Standard M?

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

Table of Contents