Your Medical Options
Core Oxford EPO 20/40
Buy-Up Oxford PPO 20/40 Oxford HDHP $1,500/90% w/HSA
Benefit Description
In-Network
In-Network
In-Network
Annual Deductible (contract year) Individual/Family
None/None
None/None
$1,500/$3,000
Out-of-Pocket Maximum Individual/Family
$3,000/$6,000
$3,000/$6,000
$5,750/$11,500
Coinsurance (Plan Pays / You Pay)
100%/0%
100%/0%
90%/10%
Lifetime Maximum
Unlimited
Unlimited
Unlimited
Preventive Care
Covered 100%
Covered 100%
Covered 100%
Doctor Office Visits Primary Care Physician Specialist
$20 copay per visit $40 copay per visit
$20 copay per visit $40 copay per visit
90% after deductible 90% after deductible
Hospital Inpatient Services 2
$400 copay per admission
$400 copay per admission
90% after deductible
Emergency Care Urgent Care Center Hospital (copay waived if admitted) Ambulance
$50copay $250 copay per visit Covered 100%
$50copay $250 copay per visit Covered 100%
90% after deductible 50% after deductible 90% after deductible
Covered 100% (designated providers) $90 copay per service
Covered 100% (designated providers) $90 copay per service
Independent X-Ray/Lab Laboratory Services Radiology
90% after deductible 90% after deductible
Outpatient Therapy 2 (60 visits per calendar year)
$40 copay per visit
$40 copay per visit
90% after deductible
Spinal Treatments 2 (Chiropractor)
$40 copay per visit
$40 copay per visit
90% after deductible
Maternity Care Prenatal and Post-Natal Care Hospital Services for Mother and Child 2
Covered 100% $400 copay per admission
Covered 100% $400 copay per admission
Covered 100% 90% after deductible
Mental Health Care Inpatient Care 2 Outpatient Visits
$400 copay per admission $20 copay per visit
$400 copay per admission $20 copay per visit
90% after deductible 90% after deductible
Substance Use and Disorders Inpatient Care 2 Outpatient Visits
$400 copay per admission $20 copay per visit
$400 copay per admission $20 copay per visit
90% after deductible 90% after deductible
Durable Medical Equipment 2
Covered 100%
Covered 100%
90% after deductible
Hearing Aids 3
Covered 100%
Covered 100%
90% after deductible
Out-of-Network Benefits 1
Oxford HDHP $1,500/90% w/HSA
Benefit Description
Core Oxford EPO 20/40
Buy-Up Oxford PPO 20/40
Annual Deductible (contract year) Individual/Family
No Coverage Out-of-Network
$4,000/$8,000
$3,000/$6,000
Out-of-Pocket Maximum Individual/Family
No Coverage Out-of-Network
$10,000/$20,000
$7,750/$15,500
Coinsurance (Plan Pays / You Pay)
No Coverage Out-of-Network
60%/40%
70%/30%
1 Out-of-Network benefit is first subject to deductible, then based on 140% of Medicare reimbursements. 2 Precertification is required. 3 Benefitislimitedtoa singlepurchase(includingrepair/replacement)everythreeyears.
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