Quick facts
Overall Deductible (Individual)
$0
Overall Deductible (Family)
$0
Out-of-Pocket Limit (Individual)
$10,600
Out-of-Pocket Limit (Family)
$21,200
Primary Care Visit Copay
$50 copayment/visit not subject to deductible
Specialist Visit Copay
$125 copayment/visit not subject to deductible
Emergency Room Care
$2,500 copayment/visit not subject to deductible (ER Facility Fee), No charge (ER Physician Fee)
Urgent Care
$75 copayment/visit not subject to deductible
More details (30)
General Coinsurance
50%
Generic Drugs (Tier 1)
$3 copayment/prescription not subject to deductible (retail, Tier 1A), $35 copayment/prescription not subject to deductible (retail, Tier 1B)
Preventive Care/Screening/Immunization
No charge
Children's Eye Exam
No charge
Children's Glasses Allowance
$150 allowance for Lenses and Frames, or Contact Lenses
Prescription Drug Deductible (Individual/Family)
$7,000 individual / $14,000 family
Diagnostic Test - X-ray
$150 copayment/visit not subject to deductible
Diagnostic Test - Lab work
$65 copayment/visit not subject to deductible
Imaging (CT/PET/MRI)
$750 copayment/visit not subject to deductible
Non-Preferred Brand Drugs (Tier 3)
50% coinsurance subject to prescription deductible (retail/mail order)
Specialty Drugs (Tier 4)
50% coinsurance subject to prescription deductible (retail/mail order)
Outpatient Surgery Facility Fee
$1,200 copayment/visit not subject to deductible (surgical and non-surgical services)
Outpatient Surgery Physician/Surgeon Fees
$350 copayment/visit not subject to deductible
Emergency Medical Transportation
$2,500 copayment/visit not subject to deductible
Hospital Facility Fee
$3,000 copayment/admission not subject to deductible
Hospital Physician/Surgeon Fees
$350 copayment/visit not subject to deductible
Mental/Behavioral Health Inpatient Services
$3,000 copayment/day not subject to deductible
Pregnancy Office Visits
No charge
Childbirth/Delivery Professional Services
$350 copayment/visit not subject to deductible
Childbirth/Delivery Facility Services
$3,000 copayment/unit not subject to deductible
Home Health Care
50% coinsurance not subject to deductible
Rehabilitation Services
$125 copayment/visit not subject to deductible
Habilitation Services
$125 copayment/visit not subject to deductible
Skilled Nursing Care
$3,000 copayment/admission not subject to deductible
Durable Medical Equipment
50% coinsurance not subject to deductible
Hospice Services
50% coinsurance not subject to deductible
Children's Glasses
50% coinsurance not subject to deductible
Children's Dental Check-up
Not Covered
Mental/Behavioral Health Outpatient Services
$125 copayment/visit not subject to deductible (office visit), $350 copayment/visit not subject to deductible (other outpatient services)
Preferred Brand Drugs (Tier 2)
$125 copayment/prescription subject to prescription deductible (retail), $375 copayment/prescription subject to prescription deductible (mail order)
Carrier contact
1-855-OSCAR-55 — member services
Your member ID card: check the carrier website or app, or ask HR for a copy.
Plan documents
Confirm details with your carrier for current plan information.