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Oscar

Silver Simple- For Diabetes

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    Plan Overview

    Combined Medical and Drug Deductible
    • Individual: $6,450
    • Family: $12,900
    • Per Person: $6,450
    Combined Medical and Drug Out of Pocket Maximum
    • Individual: $8,700
    • Family: $17,400
    • Per Person: $8,700

    Office Visit

    Primary Doctor
    • CoPay: $0.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Virtual urgent care services from Oscar designated telemedicine providers are covered in full.
    Specialist
    • CoPay: $40.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: The Member's Primary Care Physician (PCP) provides a Referral, when one is required, to a Participating Professional Provider when their condition requires a Specialist’s Services. Diabetic eye exam and diabetic foot exams are covered in full.

    Prescription Drug Information

    Preferred Brand Drugs
    • CoPay: $75.00 Copay after deductible
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Covered prescription insulin drugs are limited to a $100 copayment maximum per 30-day supply.
    Non Preferred Brand Drugs
    • CoPay: Not Applicable
    • CoInsurance: 50.00% Coinsurance after deductible
    • Covered: Covered
    • Benefit Explanation: Covered prescription insulin drugs are limited to a $100 copayment maximum per 30-day supply.
    Generic Drugs
    • CoPay: $0.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Covered prescription insulin drugs are limited to a $100 copayment maximum per 30-day supply.
    Specialty Drugs
    • CoPay: Not Applicable
    • CoInsurance: 50.00% Coinsurance after deductible
    • Covered: Covered
    • Benefit Explanation: The Health Benefit Plan will only provide benefits for covered Specialty Drugs, except Insulin, through the pharmacy benefits manager’s (PBM’s) Specialty Pharmacy Program for the appropriate cost sharing indicated in the Schedule of Benefits for a Participating Pharmacy. Benefits are available for up to a 30 day supply. Preapproval is required for those Specialty Drugs noted in the Preapproval list which is available on-line or by calling Customer Service at the phone number shown on the Member's ID card. Covered prescription insulin drugs are limited to a $100 copayment maximum per 30-day supply.

    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
    • Benefit Explanation: The Health Benefit Plan will provide coverage for surgical services provided: By a Participating Professional Provider, and/or a Participating Facility Provider; For the treatment of disease or injury.

    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

    Maternity

    Labor and Delivery Hospital Stay
    • CoPay: Not Applicable
    • CoInsurance: 50.00% Coinsurance after deductible
    • Covered: Covered
    Pre and Postnatal Office Visit
    • CoPay: Not Applicable
    • CoInsurance: 0.00%
    • Covered: Covered
    • Benefit Explanation: Pre-notification: The Health Benefit Plan should be notified of the need for maternity care within one month of the first prenatal visit to the Physician or midwife.

    Vision

    Routine Eye Exams For Children
    • CoPay: $0.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Limit Quantity: 1
    • Limit Unit : Exam(s) per Year

    Major Dental Care

    Routine Dental Checkups for Children
    • CoPay: Not Applicable
    • CoInsurance: 0.00%
    • Covered: Covered
    • Limit Quantity: 1
    • Limit Unit : Exam(s) per 6 Months
    Basic Dental Care - Child
    • CoPay: Not Applicable
    • CoInsurance: 20.00% Coinsurance after deductible
    • Covered: Covered
    Major Dental Care - Child
    • CoPay: Not Applicable
    • CoInsurance: 50.00% Coinsurance after deductible
    • Covered: Covered
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