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.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for OptimaFit Silver 5800 40% Standard M includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,900.00 | $8900 per person | $17800 per group |
| Deductible: | $5,800.00 | $5800 per person | $11600 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 OptimaFit Silver 5800 40% Standard M will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | 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: | $5,800.00 |
| Copayment: | $70.00 |
| Coinsurance: | $2,700.00 |
| Limit: | $0.00 |
| Deductible: | $100.00 |
| Copayment: | $1,000.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
| Deductible: | $2,300.00 |
| Copayment: | $200.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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.
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 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