Oscar - Bronze Elite- Specialist Saver ($3 Drugs + $0 Virtual Care)
Deductible
Separate Drug Deductible
Out-of-pocket max
Primary Care Visit
$60 Copay
100% Coinsurance
Specialist Visit
$50 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$60 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
0% Coinsurance
100% Coinsurance
Laboratory Outpatient and Professional Services
$25 Copay
100% Coinsurance
X-rays and Diagnostic Imaging
$125 Copay
100% Coinsurance
Imaging (CT/PET scans, MRIs)
$650 Copay
100% Coinsurance
Generic Drugs
$3 Copay
100% Coinsurance
Preferred Brand Drugs
$250 Copay
100% Coinsurance
Non-Preferred Brand Drugs
50% Coinsurance after deductible
100% Coinsurance
Specialty drugs
50% Coinsurance after deductible
100% Coinsurance
Outpatient Facility Fee
$1200 Copay
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
$350 Copay
100% Coinsurance
Emergency Room Services
$1000 Copay
$1000 Copay
Emergency Transportation/Ambulance
$1500 Copay
$1500 Copay
Urgent Care
$75 Copay
100% Coinsurance
Inpatient Hospital Services
50% Coinsurance after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
50% Coinsurance after deductible
100% Coinsurance
Mental/Behavioral Health Outpatient Services
$50 Copay
100% Coinsurance
Mental/Behavioral Health Inpatient Services
50% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$50 Copay
100% Coinsurance
Substance Abuse Disorder Inpatient Services
50% Coinsurance after deductible
100% Coinsurance
Prenatal and postnatal care
0% Coinsurance
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
50% Coinsurance after deductible
100% Coinsurance
Home Healthcare Services
$125 Copay
100% Coinsurance
Outpatient Rehabilitation Services
$125 Copay
100% Coinsurance
Habilitation Services
$125 Copay
100% Coinsurance
Skilled Nursing Facility
50% Coinsurance after deductible
100% Coinsurance
Durable Medical Equipment
50% Coinsurance after deductible
100% Coinsurance
Hospice Services
50% Coinsurance after deductible
100% Coinsurance
Chiropractic Care
$125 Copay
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
$125 Copay
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
$125 Copay
100% Coinsurance
Well Baby Visits and Care
0% Coinsurance
100% Coinsurance
Allergy Testing
$50 Copay
100% Coinsurance
Diabetes Education
$0 Copay
100% Coinsurance
Nutritional Counseling
$60 Copay
100% Coinsurance
Eye Exam for Children
$0 Copay
100% Coinsurance
Eye Glasses for Children
50% Coinsurance
100% Coinsurance
Accidental Dental
$350 Copay
100% Coinsurance
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
20% Coinsurance after deductible
100% Coinsurance
Dental Check Up (Child)
0% Coinsurance
100% Coinsurance
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
50% Coinsurance after deductible
100% Coinsurance
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
50% Coinsurance after deductible
100% Coinsurance
Routine Dental Services (Adult)
Not covered
Not covered