Medical Benefits for 2023
SUMMARY OF COVERAGE
Oxford – Plan 1 – EPO HSA Low Plan
Plan Provisions
In-Network
Network
Liberty
Annual Deductible (Individual/Family)
$5,500 / $11,000
Out-of-Pocket Maximum (Includes Coinsurance, & Deductible)
$6,350 / $12,700
Preventive Care
100% no deductible
Primary Physician Office Visit
70% after deductible
Specialist Office Visit
70% after deductible
Inpatient Hospital Services
70% after deductible
Outpatient Hospital Services
70% after deductible
Urgent Care
70% after deductible
Emergency Room Care
70% after deductible
Retail Prescription Drugs (30-day supply)
Tier 1 – Generic
$15 copay after deductible
Tier 2 – Formulary Brand
$35 copay after deductible
Tier 3 – Non-Formulary Brand
$75 copay after deductible
Available for employees working 30+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
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