Benefit Explanation: First (1) non-preventive visit is $50 and not subject to the deductible. Cost share applies to both in-person and telemedicine services.
Specialist
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share applies to both in-person and telemedicine services.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $250.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Generic Drugs
CoPay: $3.00
CoInsurance: Not Applicable
Covered: Covered
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full.
1-817-813-4562, TTY 711
