Platinum 90 Plan Details
Benefits in blue: Subject to a deductible
Benefits in black: Not subject to a deductible
The following benefits are for in-network services only. Before selecting a plan we recommend reviewing the plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) documents for specific costs and out-of-network benefits for PPO plans. There may be variations between plans that are not reflected here.
Standard Benefits for Individuals
Key benefits
Platinum 90
Individual Deductible
No medical deductible
No pharmacy deductible
No pharmacy deductible
Family Deductible
No medical deductible
No pharmacy deductible
No pharmacy deductible
Preventative Care Copay1
No cost
Primary Care Visit Copay
You pay $15
Specialty Care Visit Copay
You pay $30
Urgent Care Visit Copay
You pay $15
Lab Testing Copay
You pay $15
X-Ray Copay
You pay $30
Emergency Room Copay
You pay $150
Hospitalization (and high cost and infrequent services)
HMO, Oscar EPO: You pay $250 per day, up to 5 days
PPO, EPO, Sharp Performance, Kaiser Co-Insurance, Molina HMO:
You pay 10% Co-Insurance
PPO, EPO, Sharp Performance, Kaiser Co-Insurance, Molina HMO:
You pay 10% Co-Insurance
Tier 1 (most generics) Drug Copay
You pay $5
Tier 2 (preferred brand) Drug Copay
You pay $15
Tier 3 (non-preferred brand) Drug Copay
You pay $25
Tier 4 (specialty drugs)
You pay 10% Co-insurance
(Maximum cost per prescription of $250)
(Maximum cost per prescription of $250)
Maximum Out-of-Pocket For One
$3,350
Maximum Out-of-Pocket For Family
$6,700