Coverage Level 2024 Oxford Gold Freedom EPO 2024 Oxford Gold Liberty EPO Employee $33.66 $34.69 Employee + Spouse $674.81 $676.87 Employee + Child(ren) $482.47 $484.22 Employee + Family $1,219.79 $1,222.73 Employee + Domestic Partner $674.81 $676.87

In-Network

2024 Oxford Gold Freedom EPO 2024 Oxford Gold Liberty EPO General Provisions Financial Accumulation Calendar Year Calendar Year Deductible Type Embedded Embedded Deductible (Individual) $1,000 N/A Deductible (Family) $2,000 N/A Maximum Out-of-Pocket (Individual) $6,700 $7,000 Maximum Out-of-Pocket (Family) $13,400 $14,000 Copays & Coinsurance Coinsurance 10% N/A Hospitalization (Inpatient) Deductible then $250 Copay $500 Copay Surgery (Outpatient) Deductible then $250 Copay $500 Copay Urgent Care $75 Copay $50 Copay Emergency Room $500 Copay $750 Copay Laboratory Covered in full $20 Copay Radiology Deductible then $80 Copay $50 Copay Primary Care Physician (Injury or Illness) $50 Copay $25 Copay Specialist $50 Copay $50 Copay Referral required for Specialist No No Annual Physical Covered in full Covered in full Well Woman Care Covered in full Covered in full Prescriptions Prescription Deductible $150 $200 Generic Drugs (Tier 1) No deductible, $10 Copay No deductible, $10 Copay Preferred Brand Drugs (Tier 2) Deductible, then $40 Copay Deductible, then $50 copay Non-Preferred Brand Drugs (Tier 3) Deductible, then $80 Copay Deductible, then $90 copay Mail Order Rx Deductible, then 2.5x Pharmacy Copay Deductible, then 2.5x pharmacy copay

Out-Of-Network

2024 Oxford Gold Freedom EPO 2024 Oxford Gold Liberty EPO General Provisions Financial Accumulation N/A N/A Deductible Type N/A N/A Deductible (Individual) N/A N/A Deductible (Family) N/A N/A Maximum Out-of-Pocket (Individual) Not Covered N/A Maximum Out-of-Pocket (Family) Not Covered N/A Copays & Coinsurance Coinsurance N/A N/A Hospitalization (Inpatient) Not Covered Not Covered Surgery (Outpatient) Not Covered Not Covered Urgent Care Not Covered Not Covered Emergency Room $500 Copay $750 Copay Laboratory Not Covered Not Covered Radiology Not Covered Not Covered Primary Care Physician (Injury or Illness) Not Covered Not Covered Specialist Not Covered Not Covered Referral required for Specialist N/A N/A Annual Physical Not Covered Not Covered Well Woman Care Not Covered Not Covered Prescriptions Prescription Deductible N/A N/A Generic Drugs (Tier 1) Not Covered Not Covered Preferred Brand Drugs (Tier 2) Not Covered Not Covered Non-Preferred Brand Drugs (Tier 3) Not Covered Not Covered Mail Order Rx Not Covered Not Covered submitted by /u/s1jile
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