Silver Simple PCP Saver

23552TN0020025
Silver
EPO

Silver Simple PCP Saver is a Silver EPO plan by Oscar Insurance Company.

IMPORTANT: You are viewing the 2024 version of Silver Simple PCP Saver 23552TN0020025. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Silver Simple PCP Saver is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Silver Simple PCP Saver 23552TN0020025.
Insurer: Oscar Insurance Company
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 23552TN0020025

Cost-Sharing Overview

Silver Simple PCP Saver 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 PCP Saver?

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 PCP Saver offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, 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 Simple PCP Saver 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 PCP Saver 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
$20.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Prior Authorization required for Inpatient Hospice.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$75.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
$80.00 Not ApplicableNot Applicable 100.00%60.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Year Skilled Nursing and Rehabilitation Facility limited to 60 days/year combined.
Prenatal and Postnatal Care
Covered
Not Applicable 0.00%Not Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$3.00 Not ApplicableNot Applicable 100.00%
Preferred Brand Drugs
Covered
$100.00 Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner’s office, outpatient facility or home health setting.
Habilitation Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner’s office, outpatient facility or home health setting.
Chiropractic Care
Covered
$80.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for therapy, whether received in a Practitioner’s office, outpatient facility or home health setting.
Durable Medical Equipment
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Durable medical equipment over $500 requires prior authorization.
Hearing Aids
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization.
Well Baby Visits and Care
Covered
Not Applicable 0.00%Not Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$25.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Transplant services or supplies that have not received Prior Authorization will not be Covered.
Accidental Dental
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
$20.00 Not ApplicableNot Applicable 100.00% For Diabetes Treatment only.
Reconstructive Surgery
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Covered Services: Surgery to correct significant defects from congenital causes, (except where specifically excluded), accidents or disfigurement from a disease state. Reconstructive breast Surgery as a result of a mastectomy or partial mastectomy (other than lumpectomy).
Gender Affirming Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Silver Simple PCP Saver 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 PCP Saver 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 PCP Saver?

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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