Oscar

Silver Elite Rx Copay (Choice) ($0 Virtual Primary Care + $3 Drugs)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,000 Family: $14,000 Per Person: $7,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,500 Family: $17,000 Per Person: $8,500

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $450.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: See $3 drug list for Preferred Generic Rx.
Specialty Drugs	CoPay: $590.00 CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $500.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Per day copay will apply for a maximum of 3 days.
Inpatient Services	CoPay: $150.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $650.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $0 Virtual Urgent Care visits available—see SOB.

Maternity

Labor and Delivery Hospital Stay	CoPay: $500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Per day copay will apply for a maximum of 3 days.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 0.00% Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $0.00
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 : Visit(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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