Silver Classic- PCP Saver - 20069TX0100009 Health Insurance Plan

Oscar Insurance Company health insurance plan with the Plan ID 20069TX0100009. The plan is called Silver Classic- PCP Saver.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.25% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.75% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.00% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 30.00% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 20069TX0100009
Health Insurance Plan Year 2023
State Texas
Health Insurance Issuer Oscar Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 20069TX0100009-00
Provider Network(s) ['TXN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Texas All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 20069TX0100009-00

Standard On Exchange Plan - 20069TX0100009-01

Open to Indians below 300% FPL - 20069TX0100009-02

Open to Indians above 300% FPL - 20069TX0100009-03

73% AV Silver Plan - 20069TX0100009-04

87% AV Silver Plan - 20069TX0100009-05

94% AV Silver Plan - 20069TX0100009-06

Last Plan Update Date Wed, 01 Mar 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Silver Classic- PCP Saver Health Insurance Plan, 20069TX0100009-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

40.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$75.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

40.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic.

YES

$75.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.

YES

40.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

$0.00

100.00%
Dialysis
YES

40.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

40.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

$650.00 Copay after deductible

$650.00 Copay after deductible
Emergency Transportation/Ambulance
YES

$650.00 Copay after deductible

$650.00 Copay after deductible
Eye Glasses for Children
YES

50.00%

100.00%
Gender Affirming Care
YES

40.00% Coinsurance after deductible

100.00%
Generic Drugs

Oscar is on a mission to make your prescriptions more affordable. That?s why your savings start on day 1 of your new plan. $0 unlimited visits with your Oscar Virtual Primary Care team. This plan gives you access to the Oscar Virtual Primary Care through your Oscar mobile app or online account. Visits with this team are unlimited and always $0?even if you haven?t hit your deductible. Depending on your plan, if your Oscar Virtual Primary Care team prescribes you any prescriptions on the Generics: Tier 1a and Generics: Tier 1b list, 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, drugs must be prescribed by your Oscar Care virtual provider under a Silver, Gold, or Platinum plan. Virtual visits with other providers in Oscar?s network will not be free and the additional savings will not apply. Please refer to your plan documents for more information.

YES

Tier 1: $3.00

Tier 2: $25.00

100.00%
Habilitation Services

Limit: 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.

YES

$75.00

100.00%
Hearing Aids

To restore or correction of impaired speech or hearing loss.

YES

40.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

YES

$75.00

100.00%
Hospice Services

Preauthorization is required.

YES

40.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

40.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

40.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.

YES

40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

Tier 1: $10.00

Tier 2: $50.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Preauthorization is required.

YES

40.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Preauthorization is required.

YES

$75.00

100.00%
Non-Preferred Brand Drugs
YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

$30.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$30.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic.

YES

$75.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$100.00

100.00%
Prenatal and Postnatal Care
YES

$0.00

100.00%
Preventive Care/Screening/Immunization
YES

$0.00

100.00%
Primary Care Visit to Treat an Injury or Illness

Virtual visits with an Oscar Care primary 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 Primary Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Primary Care provider under a Silver, Gold, or Platinum plan.

YES

$30.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Medically necessary foot orthotics are not subject to a calendar year maximum.

YES

40.00% Coinsurance after deductible

100.00%
Radiation
YES

40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.

YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$75.00

100.00%
Rehabilitative Speech Therapy
YES

$75.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children
YES

$0.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 25.0 Visit(s) per Year

YES

40.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$75.00

100.00%
Specialty Drugs
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Preauthorization is required.

YES

40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Certain services require preauthorization.

YES

$75.00

100.00%
Transplant

Preauthorization is required.

YES

40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

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.

YES

40.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$75.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00

100.00%
X-rays and Diagnostic Imaging
YES

$75.00

100.00%

Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 20069TX0100009-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.700014244
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1
First Tier Utilization 20%
Formulary ID TXF001
Formulary URL URL
HIOS Product ID 20069TX010
Import Date 3/1/2023 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 70.25%
Issuer ID 20069
Issuer Marketplace Marketing Name Oscar Insurance Company
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers Yes
National Network No
Network ID TXN001
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
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 20069TX0100009-00
Plan Marketing Name Silver Classic- PCP Saver
Plan Type EPO
Plan Variant Marketing Name Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,600
SBC Scenario, Having a Baby, Copayment $300
SBC Scenario, Having a Baby, Deductible $6,000
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $2,400
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 80%
Service Area ID TXS001
Source Name HIOS
Plan ID 20069TX0100009
State Code TX
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $12000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $6000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $6,000
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $12000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $6000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $6,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $17300 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8650 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,650
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $17300 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8650 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,650
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Silver Classic- PCP Saver Health Insurance Plan, 20069TX0100009

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Silver Classic- PCP Saver, 20069TX0100009 Health Insurance Plan, 20069TX0100009

  • Does Silver Classic- PCP Saver Health Insurance Plan, 20069TX0100009 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (20069TX0100009) Health Insurance Plan, Variant (20069TX0100009-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (20069TX0100009) Health Insurance Plan, Variant (20069TX0100009-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (20069TX0100009) Health Insurance Plan, Variant (20069TX0100009-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services only

    Does (20069TX0100009) Health Insurance Plan, Variant (20069TX0100009-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (20069TX0100009-00) offer Disease Management Programs for Asthma?

    Yes, the Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 20069TX0100009-00 offers Disease Management Program for Asthma.

    Does Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (20069TX0100009-00) offer Disease Management Programs for Heart disease?

    Yes, the Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 20069TX0100009-00 offers Disease Management Program for Heart disease.

    Does Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (20069TX0100009-00) offer Disease Management Programs for Depression?

    Yes, the Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 20069TX0100009-00 offers Disease Management Program for Depression.

    Does Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (20069TX0100009-00) offer Disease Management Programs for Diabetes?

    Yes, the Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 20069TX0100009-00 offers Disease Management Program for Diabetes.

    Does Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (20069TX0100009-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 20069TX0100009-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (20069TX0100009-00) offer Disease Management Programs for Low back pain?

    Yes, the Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 20069TX0100009-00 offers Disease Management Program for Low back pain.

    Does Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (20069TX0100009-00) offer Disease Management Programs for Pregnancy?

    Yes, the Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 20069TX0100009-00 offers Disease Management Program for Pregnancy.

    Does Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (20069TX0100009-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Silver Classic- PCP Saver ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 20069TX0100009-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API