Bronze Classic PCP Saver Plus

58081GA0010021
Expanded Bronze
HMO

Bronze Classic PCP Saver Plus is an Expanded Bronze HMO plan by Oscar Health Plan of Georgia.

IMPORTANT: You are viewing the 2024 version of Bronze Classic PCP Saver Plus 58081GA0010021. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Bronze Classic PCP Saver Plus is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Bronze Classic PCP Saver Plus 58081GA0010021.
Insurer: Oscar Health Plan of Georgia
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 58081GA0010021

Cost-Sharing Overview

Bronze Classic PCP Saver Plus 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 PCP Saver Plus?

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 PCP Saver Plus 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 Bronze Classic PCP Saver Plus 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 PCP Saver Plus 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% 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%
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$100.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%120.0 Visit(s) per Year
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
Cosmetic Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Year
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
Not Applicable 50.00% Coinsurance after deductibleNot 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$3.00 Not ApplicableNot Applicable 100.00%
Preferred Brand Drugs
Covered
$200.00 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%40.0 Visit(s) per Year 40 visits combined per Benefit Period for Outpatient Rehabilitation Services.
Habilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%40.0 Visit(s) per Year 40 visits combined per Benefit Period for Habilitation Services.
Chiropractic Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Coverage available for Spinal Manipulation under Rehabilitative Physical Therapy benefit.
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
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% The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).
Routine Foot Care
Acupuncture
Weight Loss Programs
Covered
$0.00 Not ApplicableNot Applicable 100.00%4.0 Visit(s) per Year Medically necessary nutritional counseling for the treatment of obesity, which includes morbid obesity.
Routine Eye Exam for Children
Covered
$0.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year
Eye Glasses for Children
Covered
Not Applicable 50.00%Not Applicable 100.00%1.0 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%40.0 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%40.0 Visit(s) per Year
Well Baby Visits and Care
Covered
Not Applicable 0.00%Not Applicable 100.00% Care provided for birth through age 5.
Laboratory Outpatient and Professional Services
Covered
$25.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Only covers orthodontic treatment for a congenital anomaly related to or developed as a result of cleft palate, with or without cleft lip. Medically Necessary Orthodontia only.
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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%10000.0 Dollars per Procedure Limited to a combined maximum of $10,000 per covered organ transplant.
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
Not Applicable 50.00% Coinsurance after deductibleNot 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% Insulin infusion devices.
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
$0.00 Not ApplicableNot Applicable 100.00%4.0 Visit(s) per Year
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 Bronze Classic PCP Saver Plus 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 PCP Saver Plus 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 PCP Saver Plus?

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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