Common use of Physicians Clause in Contracts

Physicians. When you receive Covered Services from a Physician, several factors will determine your Cost Share, including whether the Physician is In-Network or Out-of-Network, the location of service, the type of Service rendered, whether the Physician participates in certain Oscar programs, and the Physician’s specialty (as determined by us). Hospitals Each time you receive inpatient or outpatient Covered Services at a Hospital, in addition to any Cost Share for Physician Services, you will have to pay the Cost Share related to Hospital Services. In-Network Hospitals have been divided into two groups, referred to as “options” on your Schedule of Benefits. Your Cost Share amount may be different for each of these options. Remember your Cost Share amount is also different for Out-of-Network Hospitals. Since not all Physicians admit patients to every Hospital, it is important when choosing a Physician that you find out the Hospitals where your Physician has admitting privileges. You can find out what Hospitals your Physician admits to by contacting the Physician’s office. This information will help you figure out what your Cost Share may be in the event you are hospitalized. Specialty Pharmacy Certain medications, such as injectable, oral, inhaled and infused therapies used to treat complex medical Conditions are typically more difficult to maintain, administer and monitor when compared to traditional drugs. Specialty Drugs may require frequent dosage adjustments, special storage and handling and may not be readily available at local pharmacies or routinely stocked by Physicians’ offices, mostly due to the high cost and complex handling they require. Using the Specialty Pharmacy to provide these Specialty Drugs should lower the amount you have to pay for these medications. Please refer to the Medication Guide for a list of Specialty Pharmacies.