Benefits for 2023
Medical
SUMMARY OF COVERAGE
Oxford – Plan 3 – PPO Low Plan - $3,000 Deductible
Plan Provisions
In-Network
Out-of-Network
Network
Liberty
Annual Deductible (Individual/Family)
$3,000 / $6,000
$6,000 / $12,000
Out-of-Pocket Maximum (Includes Coinsurance, & Deductible)
$6,000 / $12,000
$12,000 / $24,000
Lifetime Maximum
Unlimited
100%no deductible
Preventive Care
50% after deductible
Primary Physician Office Visit
$30copay
50% after deductible
Specialist Office Visit
$50copay
50% after deductible
70%after deductible 70%after deductible
Inpatient Hospital Services
50% after deductible
Outpatient Hospital Services
50% after deductible
Urgent Care
$50 copay
50% after deductible
Emergency Room Care
70% after deductible
Retail Prescription Drugs (30-day supply)
Tier 1 – Generic
$15copay
$15copay
Tier 2 – Formulary Brand
$35copay
$35copay
Tier 3 – Non-Formulary Brand
$75copay
$75copay
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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