Benefit Explanation: First three (3) non-preventive visits are $0 and not subject to the deductible. Cost share applies to both in-person and telemedicine services. Cost share applies to both in-person and telemedicine services.
Specialist
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share applies to both in-person and telemedicine services.
Prescription Drug Information
Preferred Brand Drugs
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Generic Drugs
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Specialty Drugs
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Coverage for Specialty Prescription Drugs will be limited to a supply sufficient for 34 consecutive days of therapy.
Inpatient Coverage
Hospital Services
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Blood
Inpatient Services
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Urgent Care Facility
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full once the deductible has been met.
Maternity
Labor and Delivery Hospital Stay
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Also covers surrogate mother if there is a petition to adopt within 90 days of birth. See plan documents for separate professional services cost shares.
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 0.00%
Covered: Covered
Benefit Explanation: Also covers surrogate mother if there is a petition to adopt within 90 days of birth.
Vision
Routine Eye Exams for Children
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: One (1) refraction visit per Benefit Period. Limit does not apply to all other medically necessary eye exams;
1-817-813-4562, TTY 711
