Benefits for 2023
Medical
SUMMARY OF COVERAGE
Oxford – Plan 4 – PPO High Plan - $500 Deductible
Plan Provisions
In-Network
Out-of-Network
Network
Liberty
Annual Deductible (Individual/Family)
$500 / $1,000
$1,000 / $2,000
Out-of-Pocket Maximum (Includes Medical & RX Copays, Coinsurance, & Deductible)
$3,500 / $7,000
$6,000 / $12,000
Preventive Care
100% deductible waived
60% after deductible
Primary Physician Office Visit
$25 copay
60% after deductible
Specialist Office Visit
$40 copay
60% after deductible
Inpatient Hospital Services
80% after deductible
60% after deductible
Outpatient Hospital Services
80% after deductible
60% after deductible
Urgent Care
$40 copay
60% after deductible
Emergency Room Care
$200 copay
Retail Prescription Drugs (30-day supply)
$15copay
$15copay
Tier 1 – Generic
$35copay
$35copay
Tier 2 – Formulary Brand
$75copay
$75copay
Tier3 – Non-Formulary Brand
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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