Exclusions: Telephone consultations or consultations via electronic mail or internet/web site, except as required by law or as otherwise provided in plan document
Benefit Explanation: Cost share applies to both in-person and telemedicine services.
Specialist
CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Telephone consultations or consultations via electronic mail or internet/web site, except as required by law or as otherwise provided in plan document
Benefit Explanation: Cost share applies to both in-person and telemedicine services.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $50.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications
Benefit Explanation: Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.
Non Preferred Brand Drugs
CoPay: $100.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications
Benefit Explanation: Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.
Generic Drugs
CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications
Benefit Explanation: Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.
Specialty Drugs
CoPay: $500.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications
Benefit Explanation: Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Exclusions: Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery
Benefit Explanation: There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services
Inpatient Services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Exclusions: Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery
Benefit Explanation: There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Exclusions: For care received in an emergency room, which is not, Emergency Care, including, but not limited to suture removal in an emergency room
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.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Exclusions: Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple); If Maternity Services are not covered for any reason, Hospital charges for ordinary routine nursery care for a well newborn are also not covered
Benefit Explanation: Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Perinatal Care
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 0.00%
Covered: Covered
Exclusions: Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple).
Benefit Explanation: Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient?s discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening)
1-817-813-4562, TTY 711
