Silver Simple PCP Saver
77739MI0070025
Silver
EPO
Silver Simple PCP Saver is a Silver EPO plan by Oscar Insurance Company.
Locations
Silver Simple PCP Saver is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of Silver Simple PCP Saver 77739MI0070025.
| Insurer: | Oscar Insurance Company |
| Network Type: | EPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 77739MI0070025 |
Cost-Sharing Overview
Silver Simple PCP Saver offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Silver Simple PCP Saver includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8600 per person | $17200 per group |
| Deductible: | $5500 per person | $11000 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Silver Simple PCP Saver will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $5,500 |
| Copayment: | $0 |
| Coinsurance: | $2,300 |
| Limit: | $0 |
| Deductible: | $100 |
| Copayment: | $2,300 |
| Coinsurance: | $0 |
| Limit: | $0 |
| Deductible: | $2,600 |
| Copayment: | $100 |
| Coinsurance: | $0 |
| Limit: | $0 |
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.
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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 Applicable | Not Applicable 100.00% | Cost share applies to both in-person and telemedicine services. Your PCP provides your primary health care, orders lab tests and x-rays, prescribes medicines or therapies and arranges hospitalization when necessary. Your PCP may be a family practitioner, a general practitioner, an internal medicine specialist, a pediatrician, an obstetrician/gynecologist, a nurse practitioner or a physician assistant.You may choose to seek services from a Participating Provider without referral from your PCP at any time |
| Specialist Visit Covered | $70.00 Not Applicable | Not Applicable 100.00% | Cost share applies to both in-person and telemedicine services. Referral care is care provided by a Health Professional or Physician other than your PCP. You may request a second medical opinion from a Participating Specialist Provider who has skills and training substantially similar to those of the Physician making the original treatment recommendation without Prior Approval. If there are no Participating Providers with the skills and training needed to provide a second opinion on the proposed treatment, we may Cover a second medical opinion from a Non-Participating Specialist Provider. Prior Approval from Priority Health is required before the second opinion is obtained. Any tests, procedures, treatments or surgeries recommended by the consulting Provider must be performed by a Participating Provider unless we approve the services in advance. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $20.00 Not Applicable | Not Applicable 100.00% | Your PCP may be a nurse practitioner or a physician assistant. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Outpatient services and supplies furnished by a surgery center along with a Covered surgical procedure on the day of the procedure. |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Outpatient services and supplies furnished by a surgery center along with a Covered surgical procedure on the day of the procedure. |
| Hospice Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Custodial Care is not Covered even if you receive inpatient or outpatient Hospice Care along with Custodial Care. The following Hospice Care services, provided as part of an established hospice program are Covered when your Physician informs Priority Health that your condition is terminal and Hospice Care would be appropriate: (a) Inpatient Hospice Care. Short-term inpatient care in a licensed hospice facility is Covered when Skilled Nursing Services are required and cannot be provided in other settings. Prior Approval of inpatient Hospice Care is required. (b) Outpatient Hospice Care. Outpatient care is Covered when intermittent Skilled Nursing Services by a registered nurse or a licensed practical nurse are required or when medical social services under the direction of a Physician are required. Outpatient Hospice Care is any care provided in a setting other than a licensed hospice facility. Hospice Care provided while you are in a Hospital or skilled nursing facility is considered outpatient Hospice Care. (c) Respite Care. Respite care in a facility setting is Covered as outlined in our medical policies. |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Diagnostic, counseling, and planning services for treatment of the underlying cause of infertility. Examples of Covered Services are sperm count, endometrial biopsy, hysterosalpingography, and diagnostic laparoscopy |
| 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 Applicable | Not Applicable 100.00% | Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full. Medical Emergency care and Urgent Care services are Covered under this Certificate. |
| Home Health Care Services Covered | $70.00 Not Applicable | Not Applicable 100.00% | Custodial Care is not Covered, even if you receive Covered Home Health Care or Skilled Nursing Services at the same time you receive Custodial Care. Intermittent skilled services furnished in the home by a physical therapist, occupational therapist, respiratory therapist, speech therapist, licensed practical nurse or registered nurse. Home Health Care is Covered when you are: (a) confined to the home, (b) under the care of a Physician, (c) receiving services under a plan of care established and periodically reviewed by a Physician, and (d) in need of intermittent skilled nursing care or physical, speech, or occupational therapy. |
| Emergency Room Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | Medical Emergency care and Urgent Care services are Covered. |
| Emergency Transportation/Ambulance Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | Ambulance includes a motor vehicle or aircraft that is primarily used or designated as available to provide transportation and basic life support, limited advanced life support, or advanced life support. In a Medical Emergency, we will Cover EMT and ambulance service to the nearest medical facility that can provide Medical Emergency care. We will Cover ambulance transfers between facilities that we approve in advance. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | (a) Hospital Inpatient Care. Hospital and long term acute inpatient services and supplies including services performed by Physicians and Health Professionals, room and board, general nursing care, drugs administered while you are confined as an inpatient, and related services and supplies. |
| Inpatient Physician and Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | (a) Hospital Inpatient Care. Hospital and long term acute inpatient services and supplies including services performed by Physicians and Health Professionals, room and board, general nursing care, drugs administered while you are confined as an inpatient, and related services and supplies. |
| Bariatric Surgery Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Procedure(s) per Lifetime Physician-supervised weight loss programs as outlined in our medical policies. (b) Certain surgical treatments when comorbid health conditions exist and all reasonable non-surgical options have been tried. NOTE: Surgical treatment of obesity is limited to once per lifetime unless Medically/Clinically Necessary to correct or reverse complications from a previous bariatric procedure. |
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 45.0 Days per Year Care and treatment, including therapy, and room and board in semi-private accommodations, at a skilled nursing, subacute, or inpatient rehabilitation facility is Covered when we have approved a treatment plan in advance. |
| Prenatal and Postnatal Care Covered | Not Applicable 0.00% | Not Applicable 100.00% | Covered Services(a) Hospital and Provider care. Services and supplies furnished by a Hospital or Provider for prenatal care, including genetic testing, postnatal care, Hospital delivery, and care for the Complications of Pregnancy. The mother and Newborn have the right to an inpatient stay of no less than 48 hours following a normal vaginal delivery or no less than 96 hours following a cesarean section. If the mother and her attending Physician agree, the mother and the Newborn may be discharged from the Hospital sooner. (b) Newborn child care. A Newborn child (including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities) for the first 31 days from birth. Telephone assessment and home visits by a registered nurse shortly after the date of the mother’s discharge for evaluation of the mother, Newborn and family. These services are only available if your Provider identifies a medical need. (d) Maternity education programs |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Covered Services(a) Hospital and Provider care. Services and supplies furnished by a Hospital or Provider for prenatal care, including genetic testing, postnatal care, Hospital delivery, and care for the Complications of Pregnancy. The mother and Newborn have the right to an inpatient stay of no less than 48 hours following a normal vaginal delivery or no less than 96 hours following a cesarean section. If the mother and her attending Physician agree, the mother and the Newborn may be discharged from the Hospital sooner. (b) Newborn child care. A Newborn child (including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities) for the first 31 days from birth. Telephone assessment and home visits by a registered nurse shortly after the date of the mother’s discharge for evaluation of the mother, Newborn and family. These services are only available if your Provider identifies a medical need. (d) Maternity education programs |
| Mental/Behavioral Health Outpatient Services Covered | $20.00 Not Applicable | Not Applicable 100.00% | This plan Covers evaluation, consultation and treatment necessary to determine a diagnosis and treatment plan for both acute and chronic mental health conditions. Both crisis intervention and solution-focused treatment are Covered. The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | This plan Covers evaluation, consultation and treatment necessary to determine a diagnosis and treatment plan for both acute and chronic mental health conditions. Acute Inpatient Hospitalization. |
| Substance Abuse Disorder Outpatient Services Covered | $20.00 Not Applicable | Not Applicable 100.00% | Substance abuse services, including counseling, medical testing, diagnostic evaluation and detoxification are Covered in a variety of settings. You may be treated in an inpatient or outpatient setting, depending on your particular condition. The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Substance abuse services, including counseling, medical testing, diagnostic evaluation and detoxification are Covered in a variety of settings. You may be treated in an inpatient or outpatient setting, depending on your particular condition. |
| Generic Drugs Covered | $3.00 Not Applicable | Not Applicable 100.00% | Prescription Drugs and Supplies, Drugs and supplies that are prescribed and received during a Covered inpatient stay are Covered as medical benefits.drugs for cancer therapy and the reasonable cost of administering them are Covered. |
| Preferred Brand Drugs Covered | $100.00 Not Applicable | Not Applicable 100.00% | Prescription Drugs and Supplies, Drugs and supplies that are prescribed and received during a Covered inpatient stay are Covered as medical benefits.drugs for cancer therapy and the reasonable cost of administering them are Covered. |
| Non-Preferred Brand Drugs Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Prescription Drugs and Supplies, Drugs and supplies that are prescribed and received during a Covered inpatient stay are Covered as medical benefits.drugs for cancer therapy and the reasonable cost of administering them are Covered. |
| Specialty Drugs Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Prescription Drugs and Supplies, Drugs and supplies that are prescribed and received during a Covered inpatient stay are Covered as medical benefits.drugs for cancer therapy and the reasonable cost of administering them are Covered. |
| Outpatient Rehabilitation Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 30.0 Visit(s) per Year PT/OT/Chiro – combined visits per contract year; 30 ST per contract year; 30 cardiac/ pulmonary visits per contract year. |
| Habilitation Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 30.0 Visit(s) per Year Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to-day activities that are significant in your life role, physical and occupational therapy, speech therapy for treatment of medical diagnoses, biofeedback for treatment of medical diagnoses. NOTE: Covered physical and occupational therapy services include spinal manipulations by a chiropractor and all manipulations by osteopathic Physicians. Short-term Rehabilitative Medicine Services are Covered if: Treatment is provided for an Illness, Injury or congenital defect for which you have received corrective surgery, and they are provided in an outpatient setting or in the home, and and they result in meaningful improvement in your ability to do important day-to-day activities that are necessary in your life roles within 90 days of starting treatment, and a Participating Physician refers, directs, and monitors the services. |
| Chiropractic Care Covered | $70.00 Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Year Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to-day activities that are significant in your life role, physical and occupational therapy, speech therapy for treatment of medical diagnoses, biofeedback for treatment of medical diagnoses. NOTE: Covered physical and occupational therapy services include spinal manipulations by a chiropractor and all manipulations by osteopathic Physicians. Short-term Rehabilitative Medicine Services are Covered if: Treatment is provided for an Illness, Injury or congenital defect for which you have received corrective surgery, and they are provided in an outpatient setting or in the home, and and they result in meaningful improvement in your ability to do important day-to-day activities that are necessary in your life roles within 90 days of starting treatment, and a Participating Physician refers, directs, and monitors the services. |
| Durable Medical Equipment Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | DME is equipment intended for repeated use in order to serve a medical need, is generally not useful to a person in the absence of Illness or Injury, and is appropriate for use in the home. Examples of Covered DME are manual wheelchairs, CPAP machines and glucose monitoring devices. |
| Hearing Aids Not Covered | |||
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Diagnostic and therapeutic radiology services and laboratory tests. All non-emergency laboratory tests, including high-tech radiology examinations, must be performed at a participating laboratory or facility. Radiology services and laboratory tests performed in a Hospital, either while you are an inpatient or an outpatient. |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 100.00% | Covered preventive health care services include: (a) Immunizations (doses, recommended ages, and recommended populations vary), Certain vaccines-children from birth to age 18. Certain vaccines-all adults |
| Routine Foot Care Not Covered | |||
| Acupuncture Not Covered | |||
| Weight Loss Programs Covered | $20.00 Not Applicable | Not Applicable 100.00% | Physician-supervised weight loss programs |
| Routine Eye Exam for Children Covered | $0.00 Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Year Vision Screening-all children |
| Eye Glasses for Children Covered | Not Applicable 50.00% | Not Applicable 100.00% | 1.0 Item(s) per Year Polycarbonate lenses are covered in full for children |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 30.0 Visit(s) per Year Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to-day activities that are significant in your life role, physical and occupational therapy, speech therapy for treatment of medical diagnoses, biofeedback for treatment of medical diagnoses. NOTE: Covered physical and occupational therapy services include spinal manipulations by a chiropractor and all manipulations by osteopathic Physicians. Short-term Rehabilitative Medicine Services are Covered if: Treatment is provided for an Illness, Injury or congenital defect for which you have received corrective surgery, and they are provided in an outpatient setting or in the home, and and they result in meaningful improvement in your ability to do important day-to-day activities that are necessary in your life roles within 90 days of starting treatment, and a Participating Physician refers, directs, and monitors the services. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 30.0 Visit(s) per Year Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to-day activities that are significant in your life role, physical and occupational therapy, speech therapy for treatment of medical diagnoses, biofeedback for treatment of medical diagnoses. NOTE: Covered physical and occupational therapy services include spinal manipulations by a chiropractor and all manipulations by osteopathic Physicians. Short-term Rehabilitative Medicine Services are Covered if: Treatment is provided for an Illness, Injury or congenital defect for which you have received corrective surgery, and they are provided in an outpatient setting or in the home, and and they result in meaningful improvement in your ability to do important day-to-day activities that are necessary in your life roles within 90 days of starting treatment, and a Participating Physician refers, directs, and monitors the services. |
| Well Baby Visits and Care Covered | Not Applicable 0.00% | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 40.00% Coinsurance after deductible | Not 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 40.00% Coinsurance after deductible | Not Applicable 100.00% | Evaluations for transplants and transplants of the following organs, bone marrow or stem cell, cornea, heart, kidney, liver, lung, pancreas, and small bowel. In addition, we will cover the following expenses: computer organ bank searches and any subsequent testing necessary after a potential donor is identified, unless covered by another health plan, typing or screening of a potential donor only if the person proposed to receive the transplant is a member, donor’s medical expenses directly related to or as a result of a donation surgery if the person receiving the transplant is a member and the donor’s expenses are not covered by another health benefit plan, one comprehensive evaluation per transplant. |
| Accidental Dental Not Covered | |||
| Dialysis Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to- day activities that are significant in your life roles |
| Allergy Testing Covered | $70.00 Not Applicable | Not Applicable 100.00% | Skin titration (Rinkle Method), cytotoxicity testing (Bryan’s Test), MAST testing, urine auto-injections, bronchial or oral allergen sensitization and provocative and neutralization testing for allergies. Allergy testing, evaluations and injections, including serum costs. |
| Chemotherapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | The following drugs are covered as medical benefits; Injectable and infusible drugs administered in an inpatient or emergency setting, injectable and infusible drugs requiring administration by a Health Professional in a medical office, home or outpatient facility. |
| Radiation Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Diagnostic and therapeutic radiology services and laboratory tests.. |
| Diabetes Education Covered | $0.00 Not Applicable | Not Applicable 100.00% | Diabetes educational classes to ensure that persons with diabetes are trained as to proper self-management and treatment of their diabetes. |
| Prosthetic Devices Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Prosthetic and Orthotic/Support Devices. Covered Services Surgically implanted prosthetic devices, such as a replacement hip or heart pacemaker. Externally worn prosthetic devices. Purchased, repaired or replaced prosthetics and orthotics, repairs or replacement, fitting and adjustment of Covered prosthetic and orthotic/support devices that is need as the result of normal use, body growth or change. |
| Infusion Therapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | The following drugs are covered as medical benefits; Injectable and infusible drugs administered in an inpatient or emergency setting, injectable and infusible drugs requiring administration by a Health Professional in a medical office, home or outpatient facility. |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Coverage includes medical care or services to treat dysfunction or TMJS resulting from a medical cause or injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental X-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis. |
| Nutritional Counseling Covered | $20.00 Not Applicable | Not Applicable 100.00% | 6.0 Visit(s) per Year Covered Services Consultations with a Participating dietitian, upon referral from your PCP, up to a maximum of 6 visits per Contract Year. |
| Reconstructive Surgery Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Reconstructive surgery to correct congenital birth defects and/or effects of Illness or Injury, if: The defects and/or effects of Illness or Injury cause clinical functional impairment. “Clinical functional impairment” exists when the defects and/or effects of Illness or Injury: causes significant Disability or major psychological trauma (psychological reasons do not represent a medical or surgical necessity unless you are undergoing psychotherapy for issues solely related to the Illness or Injury for which the reconstructive surgery is requested), interfere with employment or regular attendance at school, require surgery that is a component of a program of reconstructive surgery for a congenital deformity or trauma, or contribute to a major health problem. |
| Gender Affirming Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
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