Oscar Insurance Company

Gold Classic- HSA

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $2,850 Family: $5,700 Per Person: $2,850
Combined Medical and Drug Out of Pocket Maximum	Individual: $5,500 Family: $11,000 Per Person: $5,500

Office Visit

Primary Doctor	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Virtual urgent care services from Oscar designated telemedicine providers are covered in full after the deductible has been met.
Specialist	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Deductible waived for Oscar’s HSA preventive drug list.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Deductible waived for Oscar’s HSA preventive drug list.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 0.00% Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Benefit Period

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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