Oscar

Silver Simple Diabetes

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $5,900.00 Family: $11800 Per Person: $5900
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: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Diabetic eye exam 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 are covered in full.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible 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: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Exclusions: Blood
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: 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: $0.00
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;

Major Dental Care

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