Platinum 90 EPO 0-15 Child Dental

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning on or after 01/01/2020 Oscar Platinum 90 EPO 0/15 + Child Dental INF Coverage for: Individual + Family | Plan Type: EPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-855-OSCAR-55 or visit https://www.hioscar.com/forms/2020/ca. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-855-OSCAR-55 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $0 individual / $0 family See the Common Medical Events chart below for your costs for services this plan covers. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or Are there services Yes. Preventive care coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before covered before you and pre- and post-natal you meet your deductible. See a list of covered preventive services at meet your deductible? care. https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for No. You don’t have to meet deductibles for specific services. specific services? What is the out-of- The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members pocket limit for this $4,500 individual / in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been plan? $9,000 family met. What is not included in Premiums and the out-of-pocket healthcare this plan Even though you pay these expenses, they don’t count toward the out-of-pocket limit. limit? does not cover. Yes. See Will you pay less if you www.hioscar.com or This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the use a network call 1-855-OSCAR-55 most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between provider? for a list of network the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an providers. out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. Oscar Platinum 90 EPO 0/15 + Child Dental INF On-Ex Small Group CA 2020 SBC 1 of 7 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Services You Limitations, Exceptions, & Other Common Medical Event May Need Network Provider (You will pay the Out-of-Network Provider (You will Important Information least) pay the most) Primary care visit to treat an injury $15 copay/visit Deductible does not Not Covered –––––––––––none––––––––––– or illness apply $30 copay/visit Deductible does not If you visit a health care Specialist visit apply Not Covered –––––––––––none––––––––––– provider’s office or clinic You may have to pay for services that Preventive care/ aren't preventive. Ask your provider if screening/ No charge Not Covered the services you need are preventive. immunization Then check what your plan will pay for. $30 copay/visit Deductible does not Preauthorization may be required. If Diagnostic test apply (x-ray), $15 copay/visit Not Covered you don't get preauthorization, (x-ray, blood work) Deductible does not apply (lab work) payment for care may be denied. If you have a test Preauthorization is required. If you Imaging (CT/PET $75 copay/visit Deductible does not Not Covered don't get preauthorization, payment scans, MRIs) apply for care may be denied. $5 copay/30 day supply Deductible Tier 1 does not apply (retail), $12.50 Not Covered copay/90 day supply Deductible does not apply (mail order) If you need drugs to treat your illness or condition $15 copay/30 day supply Deductible Tier 2 does not apply (retail), $37.50 Not Covered –––––––––––none––––––––––– copay/90 day supply Deductible More information about does not apply (mail order) prescription drug coverage is available at $25 copay/30 day supply Deductible www.hioscar.com/search does not apply (retail), $62.50 /CA/drugs?year=2020 Tier 3 copay/90 day supply Deductible Not Covered does not apply (mail order) 10% coinsurance Deductible does Limited to a 30-day supply. Up to $250 Tier 4 not apply (retail/mail order) Not Covered per script. Oscar Platinum 90 EPO 0/15 + Child Dental INF On-Ex Small Group CA 2020 SBC 2 of 7 What You Will Pay Services You Limitations, Exceptions, & Other Common Medical Event May Need Network Provider (You will pay the Out-of-Network Provider (You will Important Information least) pay the most) Facility fee (e.g., Preauthorization may be required. If $100 copay/visit Deductible does not ambulatory apply Not Covered you don't get preauthorization, If you have outpatient surgery center) payment for care may be denied. surgery Preauthorization may be required. If Physician/surgeon $25 copay/surgery Deductible does fees not apply Not Covered you don't get preauthorization, payment for care may be denied. Emergency room $150 copay/visit Deductible does not $150 copay/visit Deductible does not apply (ER Facility Fee), No charge apply (ER Facility Fee), No charge care (ER Physician Fee) (ER Physician Fee) If you need immediate Emergency medical attention medical $150 copay/transport Deductible $150 copay/transport Deductible –––––––––––none––––––––––– transportation does not apply does not apply $15 copay/visit Deductible does not Urgent care apply Covered at in-network level Facility fee (e.g., $250 copay/admit Deductible does The $250 per day copayment will hospital room) not apply Not Covered apply for a maximum of 5 days. If you have a hospital stay Preauthorization required. If you Physician/surgeon No charge Not Covered don't get preauthorization, payment fees for care may be denied. $15 copay/visit Deductible does not If you need mental Outpatient services apply (office visit/for other outpatient Not Covered –––––––––––none––––––––––– health, behavioral health, services) or substance abuse services $250 copay/admit Deductible does The $250 per day copayment will Inpatient services not apply Not Covered apply for a maximum of 5 days. Cost-sharing does not apply to certain preventive services. Depending on the type of services, If you are pregnant Office Visit No charge Not Covered cost-sharing may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Oscar Platinum 90 EPO 0/15 + Child Dental INF On-Ex Small Group CA 2020 SBC 3 of 7 What You Will Pay Services You Limitations, Exceptions, & Other Common Medical Event May Need Network Provider (You will pay the Out-of-Network Provider (You will Important Information least) pay the most) Cost-sharing does not apply to certain preventive services. Childbirth/delivery Depending on the type of services, professional No charge Not Covered cost-sharing may apply. Maternity If you are pregnant services care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery $250 copay/admit Deductible does Not Covered The $250 per day copayment will facility services not apply apply for a maximum of 5 days. Up to 100 visits/year. $20 copay/visit Deductible does not Preauthorization is required. If you Home health care apply Not Covered don't get preauthorization, payment for care may be denied. Rehabilitation $15 copay/visit Deductible does not Preauthorization is required. If you Not Covered don't get preauthorization, payment services apply for care may be denied. Preauthorization is required. If you Habilitation $15 copay/visit Deductible does not Not Covered don't get preauthorization, payment services apply for care may be denied. If you need help Up to 100 visits per Plan Year. recovering or have other Skilled nursing $150 copay/admit Deductible does Preauthorization is required. If you special health needs care not apply Not Covered don't get preauthorization, payment for care may be denied. Preauthorization is required for Durable medical 10% coinsurance Deductible does Not Covered purchases and rentals >$500. If you equipment not apply don't get preauthorization, payment for care may be denied. Inpatient hospice care is subject to the inpatient hospital cost-sharing. Hospice services No charge Not Covered Preauthorization may be required. If you don't get preauthorization, payment for care may be denied. If your child needs dental Children’s eye or eye care exam No charge Not Covered 1 exam in a 12 month period. Oscar Platinum 90 EPO 0/15 + Child Dental INF On-Ex Small Group CA 2020 SBC 4 of 7 What You Will Pay Common Medical Event Services You Limitations, Exceptions, & Other May Need Network Provider (You will pay the Out-of-Network Provider (You will Important Information least) pay the most) 1 pair of glasses or contact lenses in Children’s glasses No charge Not Covered a 12 month period.

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