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Oxford Freedom Plan
Summary of Coverages
(A typical plan ... please call for prices)
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| Benefit |
In-Network |
Out-of-Network |
| Deductible - single |
None |
$1,000 |
| - family |
None |
$3,000 |
| Coinsurance |
None |
30% |
| Max. out of pocket - single |
Not applicable |
$4000(including deductible) |
| - family |
Not applicable |
$12,000 (including deductible) |
| Lifetime Benefit |
Unlimited |
Unlimited |
| |
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|
| Preventive Care |
| Physical Exams |
No charge |
Physical exams, routine pediatric care and immunizations are
an in network benefit only. |
| Routine Pediatric Care |
No charge |
| Immunizations |
No charge |
| Preventive dental for children under 12 |
No charge in and out |
| Outpatient Care |
| Physician office visits |
$20 copay per visit |
Subject to deductible & coinsurance |
| Surgery** |
No charge |
Subject to deductible & coinsurance** |
| Laboratory services |
at participating Labs only - No charge |
Subject to deductible & coinsurance |
| MRI |
No charge ** |
Subject to deductible & coinsurance |
| Allergy Care |
| Initial visit & all subsequent referral visits |
$20 copay per visit |
Subject to deductible & coinsurance |
| Hospital Care |
| Physicians & surgeon services** |
|
Subject to deductible & coinsurance** |
| Semi private room & board** |
$500 co pay per confinement |
Subject to deductible & coinsurance** |
| All drugs & medication |
Subject to deductible & coinsurance |
| Emergency Care |
| Oxford must be contacted within 48 hours |
| Ambulance when medically necessary |
... |
$50 copay waived if admitted |
| Hospital Emergency Room |
... |
$50 copay waived if admitted |
| Maternity Care |
| Prenatal & Post-natal care** |
$20 Copay per visit |
Subject to deductible & coinsurance** |
| Hospital services for mother & child** |
No charge |
Subject to deductible & coinsurance** |
| Short Term Rehabilitation |
| 90 outpatient visits per condition/lifetime |
$20 Copay per visit |
Subject to deductible & coinsurance |
| 60 consecutive inpatient days per condition lifetime** |
No charge |
Subject to deductible & coinsurance** |
| Home Health Care |
| 60 home care visits** |
$20 Copay per visit |
Subj. to 20% coinsurance |
| Physician house calls |
$20 Copay per visit |
Subject to deductible & coinsurance |
| Skilled Nursing facility |
| 30 days per calendar year** |
$500 copay |
Subject to deductible & coinsurance |
| Substance abuse |
| 7 days inpatient detox per cal. year** |
$500 co pay |
in network benefit only |
| 30 days inpatient rehab. per cal. year** |
$500 co pay |
in network benefit only |
| 60 outpatient rehab visits per cal. year** |
No charge |
Subject to deductible & coinsurance** |
| Mental Health Care |
| Non biologically based conditions - 30 days inpatient care per cal. year** |
|
| Biologically based - unlimited days |
$500 co pay per continuous confinement |
|
| 20 outpatient visits per cal. year for Biologically based conditions |
50% copayment** |
in network benefit only |
| Prescription Drugs*** |
$7 generic
$20 preferred brand
$50 brand name
$50 deductible per member |
Must use participating pharmacy |
| Chiropractic Care |
$20 Copay per visit |
Subject to deductible & 50% coinsurance
$500 maximum payment per calendar year |
| Hospice Care (180 days) |
| Inpatient care** |
$500 copay |
Subject to deductible & coinsurance** |
| Outpatient care** |
No charge |
Subject to deductible & coinsurance** |
Infertility Treatment
($10,000 lifetime) |
| Specialist office visits** |
$20 Copay per visit |
in network benefit only |
| Outpatient facility services** |
No charge |
in network benefit only |
| Exercise Facility |
| Subscriber |
$100 reimbursement per 6 months |
Same as In-network benefit |
| Spouse |
$50 reimbursement per 6 months |
Same as In-network benefit |
| Other coverages |
| Durable Equipment,medically necessary** |
Pre-certified by Oxford & ordered by an Oxford physician |
|
| Medical supplies when medically necessary** |
Out of network benefit only |
Subject to deductible & coinsurance** |
Dependent Eligibility - Eligible dependents include
the employee's spouse & dependent children to the age 19, or to age
23 if a full time student. Benefits discontinue till end of semester.
** These services require pre-certification through Oxford. You must call
Oxford at (800) 444-6222 at least 14 days in advance of treatment to request
pre-certification
*** Prescription medicine ordered thru the Mail Order Drug Program are subject
to the retail phqrmacy copays. The Prescription Drug benefit is based on
a Per Contract Year Limit for any applicable deductibles and/or maximum
limits.
Please Note
This sample summary of coverage is provided for information purposes only.
The applicable summary of benefits will be issued to elligible enrolled
members as part of the Certificate of Coverage. Coverage is subject to the
terms and conditions of the Certificate. You will have to refer to that
Certificate for a more complete listing of benefits, limitations, and exclusions
which include, among other services not authorized by Oxford, cosmetic surgery,
routine foot care, custodial care, personal comfort or convenience items,
private or special duty nursing, learning and behavorial disorders, Workers
Compensation, military service related conditions, hearing aids, or, unless
otherwise stated, dental services and vision correction services and supplies.
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