Oscar

Gold Elite Saver Plus

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $0.00 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $250.00 Family: $500 Per Person: $250
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,550.00 Family: $17100 Per Person: $8550

Office Visit

Primary Doctor	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share applies to both in-person and telemedicine services.
Specialist	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share applies to both in-person and telemedicine services.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $80.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $100.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $3.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: $425.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $1,000.00 Copay per Day CoInsurance: Not Applicable Covered: Covered Benefit Explanation: The per day copayment will apply for a maximum of three (3) days.
Inpatient Services	CoPay: $200.00 CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $650.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $50.00 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: $1,000.00 CoInsurance: Not Applicable Covered: Covered Exclusions: Maternity services rendered to a covered person who is acting as a gestational surrogate are excluded. Benefit Explanation: The per day copayment will apply for a maximum of three (3) days.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 0.00% Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered

Major Dental Care

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