Bronze Classic- Standard (Choice)

20069TX0200050
Expanded Bronze
EPO

Bronze Classic- Standard (Choice) is an Expanded Bronze EPO plan by Oscar Insurance Company.

IMPORTANT: You are viewing the 2023 version of Bronze Classic- Standard (Choice) 20069TX0200050. You can enroll in this plan during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

Locations

Bronze Classic- Standard (Choice) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Bronze Classic- Standard (Choice) 20069TX0200050.
Insurer: Oscar Insurance Company
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 20069TX0200050

Cost-Sharing Overview

Bronze Classic- Standard (Choice) 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- Standard (Choice)?

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- Standard (Choice) 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- Standard (Choice) 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- Standard (Choice) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$50.00 100.00%
Well Baby Visits and Care
Covered
$0.00 100.00%
Laboratory Outpatient and Professional Services
Covered
50.00% Coinsurance after deductible 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% Preauthorization is required.
Accidental Dental
Covered
50.00% Coinsurance after deductible 100.00%
Dialysis
Covered
50.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
$100.00 100.00%
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% Medically necessary foot orthotics are not subject to a calendar year maximum.
Infusion Therapy
Covered
50.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
50.00% Coinsurance after deductible 100.00% Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas.
Nutritional Counseling
Covered
$50.00 100.00% For Diabetes Treatment only.
Primary Care Visit to Treat an Injury or Illness
Covered
$50.00 100.00% Virtual visits with an Oscar Care primary 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 Primary Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Primary Care provider under a Silver, Gold, or Platinum plan.
Specialist Visit
Covered
$100.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$50.00 100.00%
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% Preauthorization is required.
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
$75.00 100.00%
Home Health Care Services
Covered
$100.00 100.00%60 Visit(s) per Year
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% All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.
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%25 Visit(s) per Year
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% Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.
Mental/Behavioral Health Outpatient Services
Covered
$50.00 100.00% Preauthorization is required.
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00% Preauthorization is required.
Substance Abuse Disorder Outpatient Services
Covered
$50.00 100.00% Certain services require preauthorization.
Substance Abuse Disorder Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00% Preauthorization is required.
Generic Drugs
Covered
$25.00 100.00% Oscar is on a mission to make your prescriptions more affordable. That?s why your savings start on day 1 of your new plan. $0 unlimited visits with your Oscar Virtual Primary Care team. This plan gives you access to the Oscar Virtual Primary Care through your Oscar mobile app or online account. Visits with this team are unlimited and always $0?even if you haven?t hit your deductible. Depending on your plan, if your Oscar Virtual Primary Care team prescribes you any prescriptions on the Generics: Tier 1a and Generics: Tier 1b list, those prescriptions will be free.* *For these savings to apply, drugs must be prescribed by your Oscar Care virtual 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. Please refer to your plan documents for more information.
Preferred Brand Drugs
Covered
$50.00 Copay after deductible 100.00%
Non-Preferred Brand Drugs
Covered
$100.00 Copay after deductible 100.00%
Specialty Drugs
Covered
$500.00 Copay after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$50.00 100.00%35 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic.
Habilitation Services
Covered
$50.00 100.00%35 Visit(s) per Year Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage.
Chiropractic Care
Covered
$100.00 100.00%35 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic.
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
50.00% Coinsurance after deductible 100.00% To restore or correction of impaired speech or hearing loss.
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
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
$0.00 100.00%
Eye Glasses for Children
Covered
50.00% 100.00%
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$50.00 100.00%
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 100.00% Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.
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- Standard (Choice) 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- Standard (Choice) 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- Standard (Choice)?

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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