Gold Elite

45819IA0010036
Gold
EPO

Gold Elite is a Gold EPO plan by Oscar Insurance Company.

IMPORTANT: You are viewing the 2023 version of Gold Elite 45819IA0010036. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Gold Elite is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Gold Elite 45819IA0010036.
Insurer: Oscar Insurance Company
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 45819IA0010036

Cost-Sharing Overview

Gold Elite 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 Gold Elite?

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

Gold Elite 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, 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 Gold Elite 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 Services only.
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency and Urgent Services only.
National Network: No

Additional Benefits and Cost-Sharing

Gold Elite 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
$25.00 100.00% Virtual visits with an Oscar Care urgent care provider are unlimited and always $0?even if you haven?t hit your deductible. Depending on your plan, many prescriptions and labs will also cost you $0, if they?re ordered by your Oscar Virtual Urgent Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan.
Specialist Visit
Covered
$50.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$25.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
30.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
30.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
30.00% Coinsurance after deductible 100.00% Care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less. Hospice respite care has a quantity limit of 15 inpatient days and 15 outpatient days per lifetime. Hospice respite care must be used in increments of not more than five days at a time.
Routine Dental Services (Adult)
Infertility Treatment
Covered
30.00% Coinsurance after deductible 100.00%
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
$50.00 100.00% Plan refers to home skilled nursing as private duty nursing. Home skilled nursing is intended to provide a safe transition from other levels of care when medically necessary, to provide teaching to caregivers for ongoing care, or to provide short-term treatments that can be safely administered in the home setting.
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$50.00 100.00%
Home Health Care Services
Covered
$50.00 100.00%
Emergency Room Services
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
30.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
30.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
30.00% Coinsurance after deductible 100.00% Surgery must be medically necessary. Not all procedures classified as weight reduction surgery are covered. Prior approval for weight reduction surgery is required.
Cosmetic Surgery
Skilled Nursing Facility
Covered
30.00% Coinsurance after deductible 100.00%
Prenatal and Postnatal Care
Covered
$0.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
30.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$50.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$50.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$3.00 100.00% Oscar is on a mission to make your prescriptions more affordable. That?s why your savings start on day 1 of your new plan. All Oscar members have access to 24/7 virtual urgent care services. Depending on your plan, if your Oscar Virtual Urgent Care provider prescribes any prescriptions on the Generics: Tier 1a or Generics: Tier 1b list during your visit, those prescriptions will be free.* Generics: Tier 1a: Drugs on this list will never cost you more than $3, no matter who prescribes them. Check to see if your prescriptions are on the $3 Prescription List at https://www.hioscar.com/prescriptions/3-dollar-list Prescriptions included in Generics: Tier 1b will always cost you less than $30, no matter who prescribes them?even if you haven?t hit your deductible. Find out which Tiers the drugs you take are on at www.hioscar.com/search *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan. Virtual visits with other providers in Oscar?s network will not be free and the additional savings will not apply.
Preferred Brand Drugs
Covered
$75.00 100.00%
Non-Preferred Brand Drugs
Covered
30.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
30.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$50.00 Copay after deductible 100.00%
Habilitation Services
Covered
$50.00 Copay after deductible 100.00% Treatment for Autism with speech therapy, occupational therapy, or physical therapy is covered. Use of Applied Behavior Analysis for the treatment of Autism is covered.
Chiropractic Care
Covered
$50.00 100.00%
Durable Medical Equipment
Covered
30.00% Coinsurance after deductible 100.00%
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
30.00% 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
$0.00 100.00%1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
50.00% 100.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$50.00 Copay after deductible 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$50.00 Copay after deductible 100.00%
Well Baby Visits and Care
Covered
$0.00 100.00% Covered for child through age 7.
Laboratory Outpatient and Professional Services
Covered
$10.00 100.00%
X-rays and Diagnostic Imaging
Covered
$75.00 100.00%
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
30.00% Coinsurance after deductible 100.00% Transplants are subject to Case Management.
Accidental Dental
Covered
30.00% Coinsurance after deductible 100.00%
Dialysis
Covered
30.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
$50.00 100.00%
Chemotherapy
Covered
30.00% Coinsurance after deductible 100.00%
Radiation
Covered
30.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$0.00 100.00%
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
30.00% Coinsurance after deductible 100.00% Intravenous administration of nutrients, antibiotics, and other drugs and fluids when provided in the home (home infusion therapy).
Treatment for Temporomandibular Joint Disorders
Covered
30.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Reconstructive Surgery
Covered
30.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
30.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Gold Elite 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 Gold Elite 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 Gold Elite?

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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