Silver Simple, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD

74289NY2770023
Silver
EPO

Silver Simple, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD is a Silver EPO plan by Oscar Insurance Corporation.

Locations

Silver Simple, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Silver Simple, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD 74289NY2770023.
Insurer: Oscar Insurance Corporation
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 74289NY2770023

Cost-Sharing Overview

Silver Simple, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD 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, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD?

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, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD 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, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD 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, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Inpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Days per Year Additional EHB Benefit
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Assistive Communication Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Step Tracking
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Orthodontia – Child
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: Yes1 Exam(s) per 6 Months One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.
Sterilization Procedures for Men
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Cardiac Rehabilitation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes210 Days per Year Also includes 5 visits for family bereavement counseling.
Primary Care Visit to Treat an Injury or Illness
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
Reconstructive Surgery
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
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Exam(s) per 6 Months
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per Year One prescribed lenses & frames in a 12-month period.
Second Opinion
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Major Dental Care – Adult
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
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Visit(s) per Year Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care Professional’s office.
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Cochlear Implants
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes One per ear per time covered.Additional EHB Benefit
Mental/Behavioral Health Outpatient Services
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
Weight Loss Programs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Not EHB
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Diabetic Equipment and Supplies
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Also includes 20 visits per year for family counseling.
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: Yes200 Days per Year
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes40 Visit(s) per Year Each visit of up to four hours by a home health aide is one visit.
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Applied Behavior Analysis Based Therapies
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
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
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per 3 Years Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.
Chiropractic 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
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Nutritional Counseling
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
Dialysis
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
Design
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes You may have access to Oscar’s $0 unlimited virtual primary care services—even if you haven’t hit your deductible. Depending on your plan, prescriptions and labs will also cost you $0, if they’re ordered by your Oscar Virtual Primary Care team.* Please refer to your plan documents for more information. *For prescriptions and lab savings to apply, they must be prescribed by your Oscar Virtual Primary Care provider under a Silver or Gold plan. Additional plan highlights include: Step tracking rewards for staying active; No referrals required; Single-tier EPO network; and Embedded deductibles.Not EHB
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Visit(s) per Year 60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inpatient Hospital Services (e.g., Hospital Stay)
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
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Visit(s) per Year 60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Prostate Cancer Screening
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Abortion for Which Public Funding is Prohibited
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Procedure(s) per Year Other Law/Regulation
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction.
Cosmetic Surgery
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
Breast Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Telemedicine
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Acupuncture
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
Family Planning Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Surgery Physician/Surgical Services
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 Any visits for home infusion therapy count towards Your home health care visit limit.
Medical Supplies
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Autologous Blood Banking
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Durable Medical Equipment
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
Preadmission Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes One external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Bariatric Surgery
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
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Visit(s) per Year 60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.
Allergy Testing
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
Contact Lenses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per Year Additional EHB Benefit
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.

Free Preventive Services

There is no copayment or coinsurance for any of the following Silver Simple, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD 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, NS, INN, Circle, Dep29, Step Tracking Rewards, Pediatric Dental, NSD?

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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