Silver Classic Standard
91908OK0010052
Silver
PPO
Silver Classic Standard is a Silver PPO plan by Oscar Insurance Company.
Locations
Silver Classic Standard is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of Silver Classic Standard 91908OK0010052.
| Insurer: | Oscar Insurance Company |
| Network Type: | PPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 91908OK0010052 |
Cost-Sharing Overview
Silver Classic Standard offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Silver Classic Standard includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8000 per person | $16000 per group |
| Deductible: | $5000 per person | $10000 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Silver Classic Standard will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | $17400 per person | $34800 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $5,000 |
| Copayment: | $20 |
| Coinsurance: | $2,500 |
| Limit: | $0 |
| Deductible: | $100 |
| Copayment: | $1,400 |
| Coinsurance: | $0 |
| Limit: | $0 |
| Deductible: | $2,200 |
| Copayment: | $300 |
| Coinsurance: | $0 |
| Limit: | $0 |
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 Silver 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
Silver 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 Silver 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
Silver 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 | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Cost share applies to both in-person and telemedicine services. Virtual primary care services provided by Oscar-designated virtual care providers are covered in full. Virtual pediatric primary care services are not available through Oscar Medical Group; these services should be obtained in-person from in-network providers. |
| Specialist Visit Covered | $80.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Cost share applies to both in person and telemedicine services. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Hospice Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | $80.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 85.0 Visit(s) per Benefit Period Pre-authorization required. |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full. |
| Home Health Care Services Covered | $80.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 30.0 Visit(s) per Benefit Period We do not pay Home Health Care Benefits for Dietician services, except as specified for diabetes self- management training; Homemaker services; Maintenance therapy; Speech Therapy; Durable Medical Equipment; Food or home – delivered meals; Intravenous drug, fluid, or nutritional therapy, except when you have received Preauthorization from the Plan for these services. |
| Emergency Room Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 30.0 Days per Benefit Period No Benefits are available: Once you can no longer improve from treatment; or for Custodial Care, or care for someone’s convenience. |
| Prenatal and Postnatal Care Covered | Not Applicable 0.00% | Not Applicable 50.00% Coinsurance after deductible | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism. |
| Generic Drugs Covered | $20.00 Not Applicable | Not Applicable 100.00% | |
| Preferred Brand Drugs Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
| Non-Preferred Brand Drugs Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Specialty Drugs Covered | $350.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Outpatient Rehabilitation Services Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 30.0 Days per Benefit Period |
| Habilitation Services Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 25.0 Visit(s) per Benefit Period |
| Chiropractic Care Covered | $80.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Durable Medical Equipment Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Hearing Aids Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | One hearing aid per ear every 48 months |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 0.00% | |
| Routine Foot Care Not Covered | |||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | $0.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 1.0 Exam(s) per Year |
| Eye Glasses for Children Covered | Not Applicable 50.00% | Not Applicable 50.00% Coinsurance after deductible | 1.0 Item(s) per Year |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 25.0 Visit(s) per Benefit Period Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined). |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 25.0 Visit(s) per Benefit Period Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined). |
| Well Baby Visits and Care Covered | Not Applicable 0.00% | Not Applicable 50.00% Coinsurance after deductible | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| 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 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Exclusions and Limitations Applicable to Organ/Tissue/Bone Marrow Transplants: The transplant must meet the criteria established by the Plan for assessing and performing organ or tissue transplants, or Bone Marrow Transplant procedures, as set forth in the Plan’s written medical policies. In addition to the Exclusions set forth elsewhere in this Certificate, no Benefits will be provided for the following organ or tissue transplants or Bone Marrow Transplants or related services: Adrenal to brain transplants; Allogeneic islet cell transplants; High-Dose Chemotherapy or High-Dose Radiation Therapy if the associated autologous or allogeneic Bone Marrow Transplant, stem cell or progenitor cell treatment, or rescue is not a Covered Service; Small bowel transplants using a living donor; Any organ or tissue transplant or Bone Marrow Transplant from a non- human donor or for the use of non-human organs for extracorporeal support and/or maintenance; Any artificial device for transplantation/implantation, except in limited instances as reflected in the Plan’s written medical policies; Any organ or tissue transplant or Bone Marrow Transplant procedure which the Plan considers to be Experimental, Investigational and/or Unproven in nature; Expenses related to the purchase, evaluation, Procurement Services or transplant procedure if the organ or tissue or bone marrow or stem cells or progenitor cells are sold rather than donated to the Subscriber recipient; All services, provided directly for or relative to any organ or tissue transplant, or Bone Marrow Transplant procedure which is not specifically listed as a Covered Service in this Certificate. The transplant must be performed in and by a Provider that meets the criteria established by the Plan for assessing and selecting Providers in the performance of organ or tissue transplants or Bone Marrow Transplant procedures. |
| Accidental Dental Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Dialysis Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Allergy Testing Covered | $80.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Issuer clarifies this is a covered benefit but stipulated under the Medical Policy and not written in the member materials. |
| Chemotherapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Radiation Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Diabetes Education Covered | $0.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Prosthetic Devices Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Infusion Therapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 25.0 Visit(s) per Benefit Period Covered under Outpatient Therapy Services. |
| Treatment for Temporomandibular Joint Disorders Not Covered | |||
| Nutritional Counseling Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Diabetes self-management training and training related to medical nutrition therapy. |
| Reconstructive Surgery Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary. |
| Gender Affirming Care Not Covered |
Free Preventive Services
There is no copayment or coinsurance for any of the following Silver 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Silver 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 Silver 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