OXFORD HEALTH INSURANCE, INC. Gold EPO 30/60 - Gated SUMMARY OF COVERAGE 5HSUHVHQWDWLYH6DPSOH Liberty Network BENEFIT FINANCIAL Deductible: Coinsurance Maximum Out-Of-Pocket: (Including Deductible) Financial Accumulation Period: Out-of-Network Reimbursement: Single Family Single Family IN-NETWORK OUT-OF-NETWORK $2,000 $4,000 50% $3,000 $6,000 Calendar Year Not Applicable Not Covered Not Covered Not Covered Not Covered Not Covered Not Applicable Not Applicable Please Note: All Copayments, Deductibles, and Coinsurance (medical and prescription) paid for In-Network Covered Services contribute to the In-Network, Out-of-Pocket Maximum. PREVENTIVE CARE Adult Preventive Care Infant and Pediatric Preventive Care Preventive Dental for Children (Up to age 19)** Pediatric Vision Exam (Up to age 19) Pediatric Vision Hardware: (Up to age 19) No Charge No Charge Deductible then No Charge $30 copay per visit 50% Coinsurance Not Covered Not Covered Not Covered Not Covered Not Covered OUTPATIENT CARE Primary Care Physician Office Visits Specialist Office Visits* Outpatient Surgery - Hospital Setting** Outpatient Surgery - Freestanding Facility** $30 copay per visit $60 copay per visit $250 copay per visit $150 copay per visit Not Covered Not Covered Not Covered Not Covered Laboratory Services** Radiology Services** No Charge Deductible then 50% Coinsurance Not Covered Not Covered MRIs, MRAs, CT SCANS, PET SCANS AND ULTRASOUND Outpatient Hospital Services** Freestanding Radiology Facility** Deductible then 50% Coinsurance Deductible then $100 copay per service Not Covered Not Covered HOSPITAL CARE Physician's and Surgeon's Services ** Semi-Private Room and Board ** Deductible then 50% Coinsurance Deductible then 50% Coinsurance Not Covered Not Covered All Drugs and Medication Deductible then 50% Coinsurance Not Covered Deductible then 50% Coinsurance $100 copay then 50% Coinsurance Deductible then 50% Coinsurance $100 copay then 50% Coinsurance $60 copay per visit Not Covered MATERNITY CARE Prenatal and Post-Natal Care ** Hospital Services for Mother and Child ** No Charge Deductible then 50% Coinsurance Not Covered Not Covered SKILLED NURSING FACILITY** Unlimited Deductible then 50% Coinsurance Not Covered HOSPICE CARE Inpatient Care** Deductible then 50% Coinsurance Not Covered Home Hospice - Unlimited** $60 copay per visit Not Covered HOME HEALTH CARE Home Care Visits - 60 visits per calendar year.** Physician House Calls $60 copay per visit $60 copay per visit Not Covered Not Covered SUBSTANCE USE DISORDER SERVICES Inpatient Rehabilitation** Deductible then 50% Coinsurance Not Covered Outpatient Rehabilitation $60 copay per visit Not Covered MENTAL HEALTH CARE Inpatient Care** Deductible then 50% Coinsurance Not Covered Outpatient Visits $60 copay per visit Not Covered ALLERGY CARE Testing and Treatment** $60 copay per visit Not Covered ALTERNATIVE MEDICINE Chiropractic Care - 30 Visits per Calendar Year** $30 copay per visit Not Covered EMERGENCY CARE Ambulance Service When Medically Necessary At Hospital Emergency Room (waived if admitted) (If member is admitted to the hospital, notification is required.) Emergency Care in Urgi-Center NHZ-HUVH\6PDOO*URXS*ROG(32*DWHG/LEHUW\1HWZRUN&DOHQGDU<HDU 5HSUHVHQWDWLYH6DPSOH 3DJHRI BENEFIT IN-NETWORK OUT-OF-NETWORK SHORT TERM REHAB & HABILITATIVE SERVICES Inpatient Visits - Unlimited Deductible then 50% Coinsurance Not Covered $50 copay per visit Not Covered No Charge Not Covered Deductible then 50% Coinsurance Not Covered No Charge Not Covered No Charge Not Covered $200 reimbursement per 6 month period $100 reimbursement per 6 month period Not Covered Not Covered Outpatient Visits - limited to 30 combined PT/OT visits per calendar year (combined with Habilitative Service). Precertification upon initial Visit** DURABLE MEDICAL EQUIPMENT Durable Medical Equipment - Unlimited** Precertification required for items over $500 MEDICAL SUPPLIES Medical Supplies When Medically Necessary HEARING AIDS Hearing Aids (Age 15 & under) - Limited to 1 hearing aid for each hearing impaired ear every 24 months. Hearing Aids (Age 16 & over) - Limited to $5,000 for each hearing impaired ear every 24 months. EXERCISE FACILITY Subscriber Spouse OUTPATIENT PRESCRIPTION DRUGS - RETAIL The Prescription Drug Benefit is based on a Per Calendar Year limit for any applicable deductibles and/or maximum limits. Tier 1 Tier 2 Tier 3 $15 copay $35 copay $75 copay Covered at participating pharmacies only Covered at participating pharmacies only Covered at participating pharmacies only OUTPATIENT PRESCRIPTION DRUGS - MAIL ORDER Tier 1 Tier 2 Tier 3 $30 copay $70 copay $150 copay Covered at participating pharmacies only Covered at participating pharmacies only Covered at participating pharmacies only DEPENDENT ELIGIBILITY: Eligible dependents include the employee's spouse and dependent children until the child reaches age 26. *Visits to an Oxford participating Specialist require an authorized referral from the member's Primary Care Physician. **These services require precertification through Oxford. Members must call Oxford at 1-800-444-6222 at least 14 days in advance of request of treatment to request precertification. **Mental health and substance use disorder services can be precertified through Oxford's Behavioral Health Department by calling 1-800-201-6991. **Precertification is required for Pediatric Orthodontia services only Please Note: This sample summary of coverage is provided for informational purposes only. The applicable Summary of Benefits will be issued to eligible enrolled members as part of the Certificate of Coverage. Coverage is subject to the terms and conditions of the Certificate. Refer to the Certificate of Coverage for a more complete listing of all benefits, limitations, and exclusions which include, among other services not authorized by Oxford, cosmetic surgery, routine foot care, custodial care, personal comfort or convenience items, private or special duty nursing, learning and behavioral disorders, Worker's Compensation, military service-related conditions, or, unless otherwise stated, dental services and vision correction services and supplies. Benefits are subject to final approval by the Department of Insurance and therefore may be subject to change. New Jersey Small Group Gold EPO $30/$60 - Gated, Liberty Network, Calendar Year Representative Sample Page 2 of 2