Gold Classic Standard

57424NE0010053
Gold
EPO

Gold Classic Standard is a Gold EPO plan by Oscar Insurance Company.

Locations

Gold Classic Standard is offered in the following counties.

Plan Overview

This is a plan overview for 2025 version of Gold Classic Standard 57424NE0010053.
Insurer: Oscar Insurance Company
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 57424NE0010053

Cost-Sharing Overview

Gold Classic Standard 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 Standard?

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 Standard 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 Standard 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 Standard 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
$30.00 Not ApplicableNot Applicable 100.00% Cost share applies to both in-person and telemedicine services.
Specialist Visit
Covered
$60.00 Not ApplicableNot Applicable 100.00% Cost share applies to both in-person and telemedicine services.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% The Covered Person must have a life expectancy of six months or less as documented in writing by the attending Physician. The Hospice Services must be ordered by a Physician. Services provided must be appropriate for palliative support or management of a Covered Person with terminal medical Illness.
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
$45.00 Not ApplicableNot Applicable 100.00% Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full.
Home Health Care Services
Covered
$60.00 Not ApplicableNot Applicable 100.00%60.0 Days per Year
Emergency Room Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Year Skilled nursing facility care does not include: a) supportive Services for a stabilized condition; b) care which can be learned and given by unlicensed or uncertified medical personnel; c) routine health care Services; d) general maintenance or supervision of routine daily activities; or e) routine administration of oral or nonprescription drugs
Prenatal and Postnatal Care
Covered
Not Applicable 0.00%Not Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00% The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Excludes programs that treat obesity or gambling addiction and residential treatment programs. Exclusions include: programs for co-dependency; employee assistance; probation; prevention; educational or self-help; programs which treat obesity, gambling, or nicotine addiction; Custodial Care for Mental Illness and/or Substance Dependence and Abuse; halfway house or Substance Dependence and Abuse maintenance programs; programs ordered by the Court determined to be not Medically Necessary.
Substance Abuse Disorder Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00% The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$15.00 Not ApplicableNot Applicable 100.00%
Preferred Brand Drugs
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Specialty Drugs
Covered
$250.00 Not ApplicableNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%45.0 Treatment(s) per Year Limits apply to rehabilitation and habilitation combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year)
Habilitation Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%45.0 Treatment(s) per Year Autism exclusions: Services for treatment of autism spectrum disorders, including but not limited to applied behavioral analysis and early intensive behavioral intervention. Services for autism spectrum disorders or pervasive developmental conditions, developmental delays or sensory integration disorders unless otherwise required by law or specifically covered elsewhere in this Contract. Health care Services that help a person keep, learn, or improve skills and functioning for daily living. These Services may include physical and occupational therapy, speech language pathology and other Services for people with disabilities in a variety of Inpatient and/or Outpatient settings. Quantitative limits on services apply to outpatient, only.
Chiropractic Care
Covered
$60.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year Chiropractic physiotherapy has a combined limit with PT, OT and speech therapies of 45 sessions per calendar year. Chiropractic manipulative adjustments have a combined limit with osteopathic physiotherapy of 20 sessions per calendar year
Durable Medical Equipment
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 25.00% 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 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
$30.00 Not ApplicableNot Applicable 100.00%45.0 Visit(s) per Year Limits apply to rehabilitation and habilitation combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year)
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%45.0 Visit(s) per Year Limits apply to rehabilitation and habilitation combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year)
Well Baby Visits and Care
Covered
Not Applicable 0.00%Not Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 25.00% 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 25.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Benefits are limited to treatment provided within 12 months of the injury. Benefits are not available for orthodontics or dental implants. Benefits shall not be provided for such Services when the Injury occurs as the result of eating, biting or chewing.
Dialysis
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Available only post-mastectomy or when required to restore, reconstruct or correct any bodily function that was lost, impaired or damaged as a result of Injury or Illness.
Gender Affirming Care
Not Covered

Free Preventive Services

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

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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