Bronze Classic- $4700 Ded

69512MO0010024
Expanded Bronze
EPO

Bronze Classic- $4700 Ded is an Expanded Bronze EPO plan by Oscar Insurance Company.

IMPORTANT: You are viewing the 2023 version of Bronze Classic- $4700 Ded 69512MO0010024. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Bronze Classic- $4700 Ded is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Bronze Classic- $4700 Ded 69512MO0010024.
Insurer: Oscar Insurance Company
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 69512MO0010024

Cost-Sharing Overview

Bronze Classic- $4700 Ded 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 Bronze Classic- $4700 Ded?

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

Bronze Classic- $4700 Ded 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 Bronze Classic- $4700 Ded 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

Bronze Classic- $4700 Ded 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
$70.00 100.00% 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
$125.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$70.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
50.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
$125.00 100.00%82 Visit(s) per Benefit Period Private duty nursing services are a Covered Service only when given as part of the ‘Home Care Services’ benefit. Private Duty Lifetime Maximum: 164 visits In- and Out-of-Network combined.
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$80.00 100.00%
Home Health Care Services
Covered
$125.00 100.00%100 Visit(s) per Benefit Period To be eligible for benefits, you must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis.
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
50.00% Coinsurance after deductible 100.00%150 Days per Benefit Period Limit is for in-and out-of-network combined and includes rehab and outpatient day rehab.
Prenatal and Postnatal Care
Covered
$0.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$70.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$70.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
50.00% 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
50.00% Coinsurance after deductible 100.00%
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$125.00 100.00%20 Visit(s) per Benefit Period To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals.
Habilitation Services
Covered
$125.00 100.00%20 Visit(s) per Benefit Period Habilitative services definition: ‘help you keep, learn or improve skills and functioning for daily living.’
Chiropractic Care
Covered
$125.00 100.00% Chiropractic visits beyond 26 per benefit period require Prior Authorization.
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
50.00% Coinsurance after deductible 100.00% Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.
Imaging (CT/PET Scans, MRIs)
Covered
50.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
$0.00 100.00%
Routine Foot Care
Covered
$0.00 100.00% Coverage is available if Medically Necessary.
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 Year Covered lenses and frames each available at limit of one per year.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$125.00 100.00% Unlimited visits for speech therapy.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$125.00 100.00%20 Visit(s) per Benefit Period 20 visit limit each for PT and OT.
Well Baby Visits and Care
Covered
$0.00 100.00%
Laboratory Outpatient and Professional Services
Covered
$25.00 100.00%
X-rays and Diagnostic Imaging
Covered
50.00% 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
50.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
50.00% Coinsurance after deductible 100.00%3000 Dollars per Episode Treatment must begin within 12 months of the injury.
Dialysis
Covered
50.00% Coinsurance after deductible 100.00% Covered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self-dialysis.
Allergy Testing
Covered
$125.00 100.00%
Chemotherapy
Covered
50.00% Coinsurance after deductible 100.00%
Radiation
Covered
50.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$0.00 100.00%
Prosthetic Devices
Covered
50.00% Coinsurance after deductible 100.00% Benefits include the purchase, fitting, adjustments, repairs and replacements.
Infusion Therapy
Covered
50.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
50.00% Coinsurance after deductible 100.00% Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.
Nutritional Counseling
Covered
$70.00 100.00%
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 100.00% Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.
Gender Affirming Care
Covered
50.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Bronze Classic- $4700 Ded 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 Bronze Classic- $4700 Ded 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 Bronze Classic- $4700 Ded?

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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