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Oscar Garden State Insurance Corporation - Secure
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Summary of Benefits and Coverage
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Drug List
Summary
Plan Type
EPO
HSA-compatible
No
Deductible & Out-of-Pocket
In Network
Out-of-Network
Deductible
Out-of-pocket max
Doctor Visit
In Network
Out-of-Network
Additional Information
Primary Care Visit
First 3 visits at No Charge, then $0 Copay after deductible
100% Coinsurance
Specialist Visit
$0 Copay after deductible
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$0 Copay after deductible
100% Coinsurance
Preventive Care/Screening/Immunization
0% Coinsurance
100% Coinsurance
Tests
In Network
Out-of-Network
Additional Information
Laboratory Outpatient and Professional Services
$0 Copay after deductible
100% Coinsurance
X-rays and Diagnostic Imaging
$0 Copay after deductible
100% Coinsurance
Imaging (CT/PET scans, MRIs)
$0 Copay after deductible
100% Coinsurance
Drugs
In Network
Out-of-Network
Additional Information
Generic Drugs
$0 Copay after deductible
100% Coinsurance
Preferred Brand Drugs
$0 Copay after deductible
100% Coinsurance
Non-Preferred Brand Drugs
$0 Copay after deductible
100% Coinsurance
Specialty drugs
$0 Copay after deductible
100% Coinsurance
Outpatient
In Network
Out-of-Network
Additional Information
Outpatient Facility Fee
$0 Copay after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
$0 Copay after deductible
100% Coinsurance
Urgent Care
In Network
Out-of-Network
Additional Information
Emergency Room Services
$0 Copay after deductible
$0 Copay after deductible
Emergency Transportation/Ambulance
0% Coinsurance after deductible
0% Coinsurance after deductible
Urgent Care
$0 Copay after deductible
$0 Copay after deductible
Hospital
In Network
Out-of-Network
Additional Information
Inpatient Hospital Services
No Charge after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
$0 Copay after deductible
100% Coinsurance
Mental / Behavioral Health
In Network
Out-of-Network
Additional Information
Mental/Behavioral Health Outpatient Services
$0 Copay after deductible
100% Coinsurance
Mental/Behavioral Health Inpatient Services
$0 Copay after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$0 Copay after deductible
100% Coinsurance
Substance Abuse Disorder Inpatient Services
$0 Copay after deductible
100% Coinsurance
Pregnancy
In Network
Out-of-Network
Additional Information
Prenatal and postnatal care
0% Coinsurance
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
$0 Copay after deductible
100% Coinsurance
Other Special Needs
In Network
Out-of-Network
Additional Information
Home Healthcare Services
$0 Copay after deductible
100% Coinsurance
Outpatient Rehabilitation Services
$0 Copay after deductible
100% Coinsurance
Habilitation Services
$0 Copay after deductible
100% Coinsurance
Skilled Nursing Facility
No Charge after deductible
100% Coinsurance
Durable Medical Equipment
0% Coinsurance after deductible
100% Coinsurance
Hospice Services
0% Coinsurance after deductible
100% Coinsurance
Chiropractic Care
No Charge after deductible
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
$0 Copay after deductible
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
$0 Copay after deductible
100% Coinsurance
Well Baby Visits and Care
0% Coinsurance
100% Coinsurance
Allergy Testing
$0 Copay after deductible
100% Coinsurance
Diabetes Education
$0 Copay after deductible
100% Coinsurance
Nutritional Counseling
$0 Copay after deductible
100% Coinsurance
Children's Vision
In Network
Out-of-Network
Additional Information
Eye Exam for Children
$0 Copay after deductible
100% Coinsurance
Eye Glasses for Children
0% Coinsurance after deductible
100% Coinsurance
Dental
In Network
Out-of-Network
Additional Information
Accidental Dental
$0 Copay after deductible
100% Coinsurance
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
0% 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)
0% Coinsurance after deductible
100% Coinsurance
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
0% Coinsurance after deductible
100% Coinsurance
Routine Dental Services (Adult)
Not covered
Not covered
Carrier Notices
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