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Gold Classic (Choice)

20069TX0200055
Gold
EPO

Gold Classic (Choice) is a Gold EPO plan by Oscar Insurance Company.

IMPORTANT: You are viewing the 2024 version of Gold Classic (Choice) 20069TX0200055. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Gold Classic (Choice) is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Gold Classic (Choice) 20069TX0200055.
Insurer: Oscar Insurance Company
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 20069TX0200055

Cost-Sharing Overview

Gold Classic (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 Gold Classic (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

Gold Classic (Choice) 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 Gold Classic (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

Gold Classic (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
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
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%60.0 Visit(s) per Year
Emergency Room Services
Covered
$650.00 Not Applicable$650.00 Not Applicable
Emergency Transportation/Ambulance
Covered
$650.00 Not Applicable$650.00 Not Applicable
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%25.0 Visit(s) 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 30.00% Coinsurance after deductibleNot Applicable 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
$40.00 Not ApplicableNot Applicable 100.00% Preauthorization is required.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required.
Substance Abuse Disorder Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 100.00% Certain services require preauthorization.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required.
Generic Drugs
Covered
$3.00 Not ApplicableNot Applicable 100.00%
Preferred Brand Drugs
Covered
$50.00 Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic.
Habilitation Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%35.0 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
$40.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic.
Durable Medical Equipment
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% To restore or correction of impaired speech or hearing loss.
Imaging (CT/PET Scans, MRIs)
Covered
$375.00 Not ApplicableNot 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%
Eye Glasses for Children
Covered
Not Applicable 50.00%Not Applicable 100.00%
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Well Baby Visits and Care
Covered
Not Applicable 0.00%Not Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$10.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
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 30.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required.
Accidental Dental
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Medically necessary foot orthotics are not subject to a calendar year maximum.
Infusion Therapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 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
Not Covered
Reconstructive Surgery
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Gold Classic (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 Gold Classic (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 Gold Classic (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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