Oxford Exclusive Plan/Freedom Network

OXFORD HEALTH INSURANCE, INC.
EPO PLAN
SUMMARY OF COVERAGE
Freedom Network
BMO Harris Bank N.A.
BENEFIT
FINANCIAL
Deductible:
Coinsurance
Maximum Out-of-Pocket:
(Including Deductible)
Financial Accumulation Period:
In-Network
Single
Family
Single
Family
None
None
None
$2,500
$5,000
Calendar Year
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
OUTPATIENT CARE
Primary Care Physician Office Visits
Specialist Office Visits
Outpatient Facility Surgery**
Laboratory Services Participating**
(See your Certificate of Coverage for additional Lab details)
MRIs, MRAs, PET Scan & CT Scan**
Radiology Services**
HOSPITAL CARE
Physician's and Surgeon's Services **
Semi-Private Room and Board **
All Drugs and Medication
EMERGENCY CARE
Ambulance Service when Medically Necessary **
At Hospital Emergency Room
(If member is admitted to the hospital, notification is required)
Emergency Care in Urgi-Center
No Charge
No Charge
$25 copay per visit
$25 copay per visit
$100 copay
No Charge
No Charge
No Charge
No Charge
$250 copay per continuous confinement
No Charge
No Charge
$100 copay per visit; waived if admitted
$25 copay per visit
MATERNITY CARE
Routine Prenatal and Post-Natal Care**
Hospital Services for Mother and Child**
No Charge
$250 copay per continuous confinement
SKILLED NURSING FACILITY
30 Days per Calendar Year**
$250 copay per continuous confinement
HOSPICE CARE
Inpatient Care**
Home Hospice Care**
$250 copay per continuous confinement
$25 copay per visit
HOME HEALTH CARE
Home Care Visits - 60 Visits per Calendar Year**
Physician House Calls**
$25 copay per visit
$25 copay per visit
SUBSTANCE USE DISORDER SERVICES
Inpatient Rehabilitation**
Outpatient Rehabilitation
Office Visits
$250 copay per continuous confinement
$25 copay per visit
$25 copay per visit
MENTAL HEALTH CARE
Inpatient Care**
Outpatient Care
Office Visits
$250 copay per continuous confinement
$25 copay per visit
$25 copay per visit
ALLERGY CARE
Testing and Treatment**
$25 copay per visit
CHIROPRACTIC CARE
Chiropractic Care**
$25 copay per visit
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January 1, 2015
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BENEFIT
In-Network
SHORT TERM REHAB & HABILITATIVE SERVICES
60 Inpatient Days per Calendar Year**
60 combined Outpatient Visits per Calendar Year**
$250 copay per continuous confinement
$25 copay per visit
DURABLE MEDICAL EQUIPMENT
Unlimited**
(Precert required for items over $500)
No Charge
HEARING AIDS
Limited to a single purchase (including repair/replacement)
every 3 Years.
No Charge
MEDICAL SUPPLIES
Medical Supplies when Medically Necessary**
No Charge
EXERCISE FACILITY
Subscriber
Spouse
$200 reimbursement per 6 month period
$100 reimbursement per 6 month period
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
$10 copay
$25 copay
$50 copay
OUTPATIENT PRESCRIPTION DRUGS - MAIL ORDER
Tier 1
Tier 2
Tier 3
$25.00 copay
$62.50 copay
$125.00 copay
DEPENDENT ELIGIBILITY:
Eligible dependents include the employee's spouse and dependent children until the child reaches age 26.
Benefits discontinue at the end of the Calendar Year
Domestic Partners covered with proper documentation.
**These services require precertification through Oxford. Members must call Oxford at 1-800-444-6222 at least 14 days in advance 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.
Please be advised this sample summary of coverage is provided for informational purposes only. The information contained herein is subject to the approval of the
New York Department of Insurance and Oxford home office approval as appropriate. 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, Workers'
Compensation, military service-related conditions, or, unless otherwise stated, dental services and vision correction services and supplies.
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January 1, 2015
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