Benefit Explanation: Virtual urgent care services from Oscar designated telemedicine providers are covered in full.
Specialist
CoPay: $55.00
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.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $250.00
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Generic Drugs
CoPay: $3.00
CoInsurance: Not Applicable
Covered: Covered
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.
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.
1-817-813-4562, TTY 711
