Oscar

Bronze Elite + PCP Saver Plus | with Atrium Health

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Medical Deductible	Individual: $0.00 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $6,500.00 Family: $13000 Per Person: $6500
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share applies to both in-person and telemedicine services.
Specialist	CoPay: $125.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share applies to both in-person and telemedicine services.

Preferred Brand Drugs	CoPay: $100.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document
Generic Drugs	CoPay: $3.00 CoInsurance: Not Applicable Covered: Covered Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document

Hospital Services

CoPay: $3,000.00 Copay per Day
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therap
Benefit Explanation: The per day copayment will apply for a maximum of two (2) days.

Inpatient Services

Emergency Room	CoPay: $2,000.00 CoInsurance: Not Applicable 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.

Labor and Delivery Hospital Stay	CoPay: $3,000.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: The per day copayment will apply for a maximum of two (2) days. See plan documents for separate professional services cost shares.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 0.00% Covered: Covered

Routine Eye Exams for Children

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered