Silver Simple

98517PA0010015
Silver
HMO

Silver Simple is a Silver HMO plan by Oscar Health Plan of Pennsylvania, Inc..

Locations

Silver Simple is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Silver Simple 98517PA0010015.
Insurer: Oscar Health Plan of Pennsylvania, Inc.
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 98517PA0010015

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
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes36 Visit(s) per Benefit Period Includes Cardiac Rehabilitation Therapy, Pulmonary Rehabilitation Therapy, Respiratory Therapy.
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Allergy Testing
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 The Health Benefit Plan will provide coverage for the following when performed after a mastectomy: Surgery to reestablish symmetry or alleviate functional impairment, including, but not limited to: Augmentation; Mammoplasty; Reduction mammoplasty; and Mastopexy.
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes20 Visit(s) per Benefit Period
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Exam(s) per Year
Specialist Visit
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
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes When prescribed by a Participating Professional Provider legally authorized to prescribe such items under law, the Health Benefit Plan will provide coverage for diabetes Outpatient self management training and education, including medical nutrition.
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Exam(s) per 6 Months
Orthodontia – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes24 Months per Lifetime Orthodontic treatment must be Medically Necessary.
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Prosthetic Devices
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
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Benefit Period Occupational Therapy: Coverage will also include services rendered by a registered, licensed occupational therapist. The Member is required to have these services performed by the Member’s Primary Care Physician’s Designated Provider. Physical Therapy: Includes treatment by physical means, heat, hydrotherapy or similar modalities, physical agents, bio- mechanical and neuro-physiological principles, and devices to relieve pain, restore maximum function, and prevent disability following disease, injury, or loss of body part. The Member is required to have these services performed by the Member’s Primary Care Physician’s Designated Provider.
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Visit(s) per Benefit Period
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per Year
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Dialysis treatment when provided in the Outpatient facility of a Hospital, a free-standing renal Dialysis facility or in the home. In the case of home Dialysis, Covered Services will include equipment, training, and medical supplies.
Urgent Care Centers or Facilities
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 The Health Benefit Plan will only provide benefits for covered Specialty Drugs, except Insulin, through the pharmacy benefits manager’s (PBM’s) Specialty Pharmacy Program for the appropriate cost sharing indicated in the Schedule of Benefits for a Participating Pharmacy. Benefits are available for up to a 30 day supply. Preapproval is required for those Specialty Drugs noted in the Preapproval list which is available on-line or by calling Customer Service at the phone number shown on the Member’s ID card.
Abortion for Which Public Funding is Prohibited
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes6 Visit(s) per Benefit Period Counseling visits or session need to be performed and billed by any of the following Providers, in an office setting: Member’s Physician, Referred Specialist, or Registered Dietitian.
Transplant
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
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Depending on your plan, many lab orders are $0 when they are ordered by a member of your Oscar Virtual Urgent Care provider.* Some orders are unavailable via virtual visits. In-network labs with non-preferred providers are available at a higher cost. 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.
Treatment for Temporomandibular Joint Disorders
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes120 Days per Benefit Period 120 Inpatient days for the Benefit Period Maximum.
X-rays and Diagnostic Imaging
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
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
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
Emergency Transportation/Ambulance
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 The initial treatment of Accidental Injury/trauma (That is, fractured facial bones and fractured jaws), in order to restore proper function. Restoration of proper function includes the dental services required for the initial restoration or replacement of Sound Natural Teeth, required for the initial treatment for the Accidental Injury/trauma.
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Artificial Insemination is covered: Facility services provided by a Participating Facility Provider and services performed by a Referred Specialist for the promotion of fertilization of a female recipient’s own ova (eggs).
Mental/Behavioral Health Inpatient Services
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 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 prescriptions on the Generics: Tier 1a or Generics: Tier 1b list during your visit, those prescriptions will be free.* Generics: Tier 1a: Drugs on this list will never cost you more than $3, no matter who prescribes them. Check to see if your prescriptions are on the $3 Prescription List at https://www.hioscar.com/prescriptions/3-dollar-list Prescriptions included in Generics: Tier 1b will always cost you less than $30, no matter who prescribes them—even if you haven’t hit your deductible. 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 free and the additional savings will not apply.
Major Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Private-Duty Nursing
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 The Health Benefit Plan will provide coverage for surgical services provided: By a Participating Professional Provider, and/or a Participating Facility Provider; For the treatment of disease or injury.
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Infusion therapy includes all professional services, supplies, and equipment that are required to safely and effectively administer the therapy.
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes36 Visit(s) per Benefit Period Limit 36 visits per benefit period for Cardiac Rehabilitation Therapy, Pulmonary Rehabilitation Therapy, and Respiratory Therapy. Limit 30 visits per benefit period for speech therapy. Combined limit of 30 visits per benefit period for physical therapy and occupational therapy.
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Benefit Period Includes treatment for the correction of a speech impairment resulting from disease, Surgery, injury, congenital anomalies, or previous therapeutic processes. Coverage will also include services by a speech therapist.
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Respite Care: If the Member were to receive Hospice Care primarily in the home, the Member’s primary caregiver may need to be relieved, maximum of seven days every six months. In such a case, the Health Benefit Plan will provide coverage for the Member to receive the same kind of care.
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Other Practitioner Office Visit (Nurse, Physician Assistant)
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 lab and prescription drug savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver or Gold plan.
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Pre-notification: The Health Benefit Plan should be notified of the need for maternity care within one month of the first prenatal visit to the Physician or midwife.
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Chemotherapeutic agents, if administered intravenously or intramuscularly (through intraarterial injection, infusion, perfusion or subcutaneous, intracavitary and oral routes) will be covered.
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Bariatric Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Acupuncture
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Hearing Aids
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
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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