Silver Simple Diabetes Guided Care

20069TX0510013
Silver
HMO

Silver Simple Diabetes Guided Care is a Silver HMO plan by Oscar Insurance Company.

Locations

Silver Simple Diabetes Guided Care is offered in the following counties.

Plan Overview

This is a plan overview for 2025 version of Silver Simple Diabetes Guided Care 20069TX0510013.
Insurer: Oscar Insurance Company
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 20069TX0510013

Cost-Sharing Overview

Silver Simple Diabetes Guided Care 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 Diabetes Guided Care?

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 Diabetes Guided Care offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Pregnancy
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: All specialists except Behavioral Health, Obstetrics and Gynecology require a referral
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Silver Simple Diabetes Guided Care 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 Diabetes Guided Care 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
$0.00 Not ApplicableNot Applicable 100.00% Cost share applies to both in-person and telemedicine services.
Specialist Visit
Covered
$40.00 Not ApplicableNot Applicable 100.00% Diabetic eye exams and diabetic foot exams are covered in full. Cost share applies to both in-person and telemedicine services.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$0.00 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% Preauthorization is required.
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
$75.00 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
$40.00 Not ApplicableNot Applicable 100.00%60.0 Visit(s) per Year Benefits will not be provided for Home Health Care for Food or home delivered meals; Social case work or homemaker services; Services provided primarily for Custodial Care; Transportation services; Home Infusion Therapy; and Durable medical equipment.
Emergency Room Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%25.0 Visit(s) per Year
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% Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated cesarean section.
Mental/Behavioral Health Outpatient Services
Covered
$0.00 Not ApplicableNot Applicable 100.00% Preauthorization is required.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required.
Substance Abuse Disorder Outpatient Services
Covered
$0.00 Not ApplicableNot Applicable 100.00% Certain services require preauthorization.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required.
Generic Drugs
Covered
$0.00 Not ApplicableNot Applicable 100.00% Preferred generic drugs are covered in full.
Preferred Brand Drugs
Covered
$75.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic.
Habilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%35.0 Visit(s) per Year Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage
Chiropractic Care
Covered
$40.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic.
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Durable medical equipment not provided for Home Health Care. Rental covered under medical/surgical. Excluded from pharmacy benefits, but permitted for diabetes and self-administered injections. Female contraception and breast pumps covered under medical/surgical benefits.
Hearing Aids
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% To restore or correction of impaired speech or hearing loss.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00% 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
Certain weight loss services such as nutritional and diet counseling are available through a diabetes management plan, autism benefits, and for adults at higher risk of chronic disease.
Routine Eye Exam for Children
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Eye Glasses for Children
Covered
Not Applicable 50.00%Not Applicable 100.00%
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Well Baby Visits and Care
Covered
Not Applicable 0.00%Not Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$65.00 Not ApplicableNot Applicable 100.00% Labs (HbA1c screening, urinalysis, metabolic panel, lipid panel) to manage diabetes are covered in full.
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00% 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 50.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required.
Accidental Dental
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$40.00 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% Medically necessary foot orthotics are not subject to a calendar year maximum.
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 any non-surgical (dental restorations, orthodontics, or physical therapy) or non-diagnostic services or supplies (oral appliances, oral splints, oral orthotics, devices, or prosthetics) provided for the treatment of the temporomandibular joint and all adjacent or related muscles and nerves. Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas.
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Silver Simple Diabetes Guided Care 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 Simple Diabetes Guided Care 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 Simple Diabetes Guided Care?

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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