Silver Simple Diabetes | MercyOne

45819IA0010045
Silver
EPO

Silver Simple Diabetes | MercyOne is a Silver EPO plan by Oscar Insurance Company.

IMPORTANT: You are viewing the 2024 version of Silver Simple Diabetes | MercyOne 45819IA0010045. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Silver Simple Diabetes | MercyOne is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Silver Simple Diabetes | MercyOne 45819IA0010045.
Insurer: Oscar Insurance Company
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 45819IA0010045

Cost-Sharing Overview

Silver Simple Diabetes | MercyOne 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 Silver Simple Diabetes | MercyOne?

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

Silver Simple Diabetes | MercyOne offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Pregnancy
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 Silver Simple Diabetes | MercyOne 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

Silver Simple Diabetes | MercyOne 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
$0.00 Not ApplicableNot Applicable 100.00% Cost share applies to both in-person and virtual services.
Specialist Visit
Covered
$40.00 Not ApplicableNot Applicable 100.00% Diabetic eye exam and diabetic foot exams are covered in full. Cost share applies to both in-person and virtual services.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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)
Not Covered
Infertility Treatment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
$40.00 Not ApplicableNot Applicable 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)
Not Covered
Urgent Care Centers or Facilities
Covered
$75.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Emergency Room Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Prenatal and Postnatal Care
Covered
Not Applicable 0.00%Not Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Preferred Brand Drugs
Covered
$75.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Habilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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 not covered.
Chiropractic Care
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$0.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
Not Applicable 50.00%Not Applicable 100.00%1.0 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Well Baby Visits and Care
Covered
Not Applicable 0.00%Not Applicable 100.00% Covered for child through age 7.
Laboratory Outpatient and Professional Services
Covered
$10.00 Not ApplicableNot Applicable 100.00% Labs (HbA1c screening, urinalysis, metabolic panel, lipid panel) to manage diabetes are covered in full.
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
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 50.00% Coinsurance after deductibleNot Applicable 100.00% Transplants are subject to Case Management.
Accidental Dental
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Gender Affirming Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Silver Simple Diabetes | MercyOne 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 Silver Simple Diabetes | MercyOne 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 Silver Simple Diabetes | MercyOne?

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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