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.
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
Inpatient Coverage
Hospital Services
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Exclusions: Inpatient stays primarily for therapy (such as physical or occupational therapy). Private room when not Authorized by the Plan and room and board charges are in excess of semi-private room. Services that could be provided in a less intensive setting.
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.
1-817-813-4562, TTY 711
