Silver Simple

23818NJ0010003
Silver
EPO

Silver Simple is a Silver EPO plan by Oscar Garden State Insurance Corporation.

Locations

Silver Simple is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Silver Simple 23818NJ0010003.
Insurer: Oscar Garden State Insurance Corporation
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 23818NJ0010003

Cost-Sharing Overview

Silver Simple 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 Simple?

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 Simple offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol
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 Simple 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 Simple includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Acupuncture
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Only covered when used as an alternative to anesthesia.
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes For the first 180 days of the plan year, no prior authorization or other prospective utilization management is required.
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Private-Duty Nursing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Oscar only covers charges by a Nurse for Medically Necessary and Appropriate private duty nursing care if such care is authorized as part of a written home health care plan, coordinated by a Home Health Agency, and covered under the Home Health Care Charges section.
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Bariatric Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Abortion for Which Public Funding is Prohibited
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per Year Vision benefits described in this provision for Covered Persons through age 18. We cover one pair of lenses, for glasses or contact lenses, and one pair of frames.
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Exam(s) per Year Covers vision screening for Dependent children, through age 17.
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Prescription drug copayment, deductible, and coinsurance liability will not exceed $150 per prescription drug per 30 day supply. Applies to outpatient drugs and not to drugs secured in an office or facility.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Cost sharing may vary based on the place of service.
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Other Law/Regulation
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Prescription drug copayment, deductible, and coinsurance liability will not exceed $150 per prescription drug per 30 day supply. Applies to outpatient drugs and not to drugs secured in an office or facility.
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Year Up to 30 visits/year each for Physical, Occupational, Speech, and Cognitive Therapy.
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Oscar does provide coverage for treatment of a congenital abnormality or a developmental anomaly.
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Prescription drug copayment, deductible, and coinsurance liability will not exceed $150 per prescription drug per 30 day supply. Applies to outpatient drugs and not to drugs secured in an office or facility.
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Year Up to 30 visits/year each for Physical, Occupational, Speech, and Cognitive Therapy.
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Cost-share waived if admitted.
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes For the first 28 days of of the plan year, the facility is to provide us notice of admission and a submission of an initial treatment plan within 48 hours of your admission. After the first 28 days and until the 180th day of the plan year, concurrent review is required at 2 week intervals, 24 hour prior notice of denial, 24 hour internal and external appeal period, benefits will continue to be provided through the day after notification of denial.
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Lab work performed by Quest Labs is covered at no charge. Depending on your plan, many lab orders are $0 when they are ordered by your Oscar Virtual Urgent Care provider.* Some orders are unavailable via virtual visits. Please refer to your plan documents for more information. *For these savings to apply, they must be ordered by your Oscar Virtual Urgent Care provider under a Silver or Gold plan.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Year Up to 30 visits/year each for Physical, Occupational, Speech, and Cognitive Therapy. Services to treat autism and other developmental disabilities are not subject to the 30-visit limit or preauthorization requirements.
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Year Referred to as therapeutic manipulation.
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per 2 Years One hearing aid per age 15 or younger hearing impaired ear per 24-month period.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Year Up to 30 visits/year each for Physical, Occupational, Speech, and Cognitive Therapy.
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Prescription drug copayment, deductible, and coinsurance liability will not exceed $150 per prescription drug per 30 day supply. Applies to outpatient drugs and not to drugs secured in an office or facility. Oscar is on a mission to make your prescriptions more affordable. That’s why your savings start on day 1 of your new plan. All Oscar members have access to 24/7 virtual urgent care services. Depending on your plan, if your Oscar Virtual Urgent Care provider prescribes any Tier 1 Generic prescriptions during your visit, those prescriptions will be $0.* Find out which Tiers the drugs you take are on at www.hioscar.com/search *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver or Gold plan. Virtual visits with other providers in Oscar’s network will not be $0 and the additional savings will not apply. Find out which Tiers the drugs you take are on at www.hioscar.com/search
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Orthodontia – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Virtual visits with an Oscar Care urgent 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 Urgent Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver or Gold plan.
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes The policy covers non-surgical care and treatment which includes diagnostic services. Allergy testing is covered as a diagnostic service.
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Major Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes

Free Preventive Services

There is no copayment or coinsurance for any of the following Silver Simple 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.

Ready to sign up for Silver Simple?

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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