Silver Classic | with Atrium Health

69803NC0010063
Silver
HMO

Silver Classic | with Atrium Health is a Silver HMO plan by Oscar Health Plan of North Carolina, Inc.

Locations

Silver Classic | with Atrium Health is offered in the following counties.

Plan Overview

This is a plan overview for 2025 version of Silver Classic | with Atrium Health 69803NC0010063.
Insurer: Oscar Health Plan of North Carolina, Inc
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 69803NC0010063

Cost-Sharing Overview

Silver Classic | with Atrium Health 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 Silver Classic | with Atrium Health?

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 | with Atrium Health 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 | with Atrium Health 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 | with Atrium Health 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
$80.00 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 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% Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation. Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%3.0 Treatment(s) per Lifetime
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
$80.00 Not ApplicableNot Applicable 100.00% Excludes services provided by a close relative or a member of the household
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$80.00 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
$80.00 Not ApplicableNot Applicable 100.00% Excludes homemaker services, such as cooking and housekeeping; Dietitian services or meals; Services that are provided by a close relative or a member of the household.
Emergency Room Services
Covered
$750.00 Copay after deductible Not Applicable$750.00 Copay after deductible Not Applicable
Emergency Transportation/Ambulance
Covered
$750.00 Copay after deductible Not Applicable$750.00 Copay after deductible Not Applicable Excludes services provided primarily for the convenience of travel, transportation to or from a doctor’s office or dialysis center, transportation for the purpose of receiving services that are not considered Covered Services
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therap
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Benefit Period
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% See plan documents for separate professional services cost shares.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00% Excludes counseling with relatives about a patient 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 50.00% Coinsurance after deductibleNot Applicable 100.00% Excludes, “Inpatient confinements that are primarily intended as a change of environment”; Counseling with relatives of a patient
Substance Abuse Disorder Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00% Excludes counseling with relatives about a patient 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 50.00% Coinsurance after deductibleNot Applicable 100.00% Excludes, “Inpatient confinements that are primarily intended as a change of environment”; Counseling with relatives of a patient
Generic Drugs
Covered
$3.00 Not ApplicableNot Applicable 100.00% Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document
Preferred Brand Drugs
Covered
$75.00 Not ApplicableNot Applicable 100.00% Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document
Outpatient Rehabilitation Services
Covered
$80.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Benefit Period Applied Behavior Analysis (ABA) therapy; Cognitive therapy; Speech therapy for stammering or stuttering; Group classes for pulmonary rehabilitation; music therapy, remedial reading, recreational or activity therapy, all forms or special education and supplies or equipment used similarly; maintenance therapy; massage therapy. Combined 30 visit limit for occupational and physical therapies and chiropractic services.
Habilitation Services
Covered
$80.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Benefit Period Cognitive Therapy. Group classes for pulmonary rehabilitation. Combined 30 visit limit for occupational and physical therapies and chiropractic services.
Chiropractic Care
Covered
$80.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Benefit Period 30 visit limits for PT and OT combined (including chiropractic).
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime.
Hearing Aids
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids, once every 36 months.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Lab tests that are not ordered by Doctor of Other Provider.
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 Benefit Period
Eye Glasses for Children
Covered
Not Applicable 50.00%Not Applicable 100.00%1.0 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$80.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Benefit Period
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$80.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services
Well Baby Visits and Care
Covered
Not Applicable 0.00%Not Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$50.00 Not ApplicableNot Applicable 100.00% Lab tests that are not ordered by a Doctor or Other Provider.
X-rays and Diagnostic Imaging
Covered
$70.00 Not ApplicableNot Applicable 100.00% Lab tests that are not ordered by a Doctor or Other Provider.
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 50.00% Coinsurance after deductibleNot Applicable 100.00% The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organ or tissues. Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient’s coverage
Accidental Dental
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Excludes injury related to chewing or biting.
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$80.00 Not ApplicableNot 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% Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan. Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery.
Infusion Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Excludes Treatment for periodontal disease; Dental implants or root canals; Crowns and bridges; Orthodontic brace; Occlusal (bite) adjustments; Extractions. Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.
Nutritional Counseling
Covered
$30.00 Not ApplicableNot Applicable 100.00% Nutritional counseling visits are separate from the obesity-related office visits
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Silver Classic | with Atrium Health 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 Silver Classic | with Atrium Health 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 | with Atrium Health?

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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