Benefit Explanation: Cost share applies to both in-person and telemedicine services.
Specialist
CoPay: $35.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Qualified specialist visits for cardiology, pulmonology, and endocrinology are covered in full. Diabetic eye exams and diabetic foot exams are covered in full. Cost share applies to both in-person and telemedicine services.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $75.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Generic Drugs
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Preferred generic drugs, including common prescription generic statins, antiasthmatics, and bronchodilators (inhalers), are covered in full.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.
Inpatient Services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
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
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
Benefit Explanation: Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated cesarean section.
1-817-813-4562, TTY 711
