OXFORD HEALTH INSURANCE, INC.
Platinum PPO Flex 15/45 - Non-Gated
SUMMARY OF COVERAGE
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Liberty Network
BENEFIT
FINANCIAL
Deductible:
Coinsurance
Maximum Out-Of-Pocket:
(Including Deductible)
Financial Accumulation Period:
Out-of-Network Reimbursement:
Single
Family
Single
Family
IN-NETWORK
OUT-OF-NETWORK
None
None
None
$2,500
$5,000
Calendar Year
Not Applicable
$2,500
$5,000
30%
$6,250
$12,500
Calendar Year
High UCR
Please Note: All Copayments, Deductibles, and Coinsurance (medical and prescription) paid for In-Network Covered Services contribute to the In-Network, Out-of-Pocket Maximum.
PREVENTIVE CARE
Adult Preventive Care
Infant and Pediatric Preventive Care
Preventive Dental for Children (Up to age 19)**
Pediatric Vision Exam (Up to age 19)
Pediatric Vision Hardware: (Up to age 19)
No Charge
No Charge
$100 Deductible then No Charge
$15 copay per visit
50% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then No Charge
Deductible then $15 copay per visit
Deductible then 50% Coinsurance
$15 copay per visit
$45 copay per visit
$150 copay per visit
No Charge
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
No Charge
No Charge
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
$100 copay per service
$50 copay per service
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
No Charge
$300 copay per day. $1,500 max per admission. $3,000 max per
Calendar Year.
No Charge
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
No Charge
$100 copay per visit
No Charge
$100 copay per visit
$45 copay per visit
Deductible then 30% Coinsurance
No Charge
$300 copay per day. $1,500 max per admission. $3,000 max per
Calendar Year.
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
$300 copay per day. $1,500 max per admission. $3,000 max per
Calendar Year.
Deductible then 30% Coinsurance
$300 copay per day. $1,500 max per admission. $3,000 max per
Calendar Year.
Deductible then 30% Coinsurance
Home Hospice - Unlimited**
No Charge
Deductible then 30% Coinsurance
HOME HEALTH CARE
Home Care Visits - 60 visits per calendar year.**
Physician House Calls
No Charge
$45 copay per visit
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
$300 copay per day. $1,500 max per admission. $3,000 max per
Calendar Year.
$45 copay per visit
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Outpatient Visits
$300 copay per day. $1,500 max per admission. $3,000 max per
Calendar Year.
$45 copay per visit
ALLERGY CARE
Testing and Treatment**
$45 copay per visit
Deductible then 30% Coinsurance
ALTERNATIVE MEDICINE
Chiropractic Care - 30 Visits per Calendar Year**
$30 copay per visit
Deductible then 30% Coinsurance
OUTPATIENT CARE
Primary Care Physician Office Visits
Specialist Office Visits
Outpatient Surgery - Hospital Setting**
Outpatient Surgery - Freestanding Facility**
*Outpatient Surgery Non-Network Limited to $2,000.
Laboratory Services**
Radiology Services**
MRIs, MRAs, CT SCANS, PET SCANS AND ULTRASOUND
Outpatient Hospital Services**
Freestanding Radiology Facility**
HOSPITAL CARE
Physician's and Surgeon's Services **
Semi-Private Room and Board **
All Drugs and Medication
EMERGENCY CARE
Ambulance Service When Medically Necessary
At Hospital Emergency Room (waived if admitted)
(If member is admitted to the hospital, notification is required.)
Emergency Care in Urgi-Center
MATERNITY CARE
Prenatal and Post-Natal Care **
Hospital Services for Mother and Child **
SKILLED NURSING FACILITY**
120 days per Calendar Year Non-Network. Combined with
Inpatient Rehabilitation
HOSPICE CARE
Inpatient Care**
SUBSTANCE USE DISORDER SERVICES
Inpatient Rehabilitation**
Outpatient Rehabilitation
MENTAL HEALTH CARE
Inpatient Care**
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Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
3DJHRI
BENEFIT
SHORT TERM REHAB & HABILITATIVE SERVICES
Limited to 120 Inpatient days Non-Network per Calendar Year.
Combined with Skilled Nursing
Outpatient Visits - limited to 30 combined PT/OT visits per
calendar year (combined with Habilitative Service).
IN-NETWORK
OUT-OF-NETWORK
$300 copay per day. $1,500 max per admission. $3,000 max per
Calendar Year.
$45 copay per visit
Deductible then 30% Coinsurance
No Charge
Deductible then 30% Coinsurance
No Charge
Deductible then 30% Coinsurance
No Charge
Deductible then 30% Coinsurance
No Charge
Deductible then 30% Coinsurance
$200 reimbursement per 6 month period
$100 reimbursement per 6 month period
$200 reimbursement per 6 month period
$100 reimbursement per 6 month period
Deductible then 30% Coinsurance
Precertification upon initial Visit**
DURABLE MEDICAL EQUIPMENT
Durable Medical Equipment - Unlimited**
Precertification required for items over $500
MEDICAL SUPPLIES
Medical Supplies When Medically Necessary
HEARING AIDS
Hearing Aids (Age 15 & under) - Limited to 1 hearing aid for
each hearing impaired ear every 24 months.
Hearing Aids (Age 16 & over) - Limited to $5,000 for each
hearing impaired ear every 24 months.
EXERCISE FACILITY
Subscriber
Spouse
OUTPATIENT PRESCRIPTION DRUGS - RETAIL
The Prescription Drug Benefit is based on a Per Calendar Year limit for any applicable deductibles and/or maximum limits.
Tier 1
Tier 2
Tier 3
$10 copay
$25 copay
$50 copay
$10 copay
$25 copay
$50 copay
OUTPATIENT PRESCRIPTION DRUGS - MAIL ORDER
Tier 1
Tier 2
Tier 3
$20 copay
$50 copay
$100 copay
$20 copay
$50 copay
$100 copay
DEPENDENT ELIGIBILITY:
Eligible dependents include the employee's spouse and dependent children until the child reaches age 26.
**These services require precertification through Oxford. Members must call Oxford at 1-800-444-6222 at least 14 days in advance of
request of treatment to request precertification.
**Mental health and substance use disorder services can be precertified through Oxford's Behavioral Health Department by calling 1-800-201-6991.
**Precertification is required for Pediatric Orthodontia services only
Please Note: This sample summary of coverage is provided for informational purposes only. The applicable Summary of Benefits will be issued to eligible enrolled members as part of the
Certificate of Coverage. Coverage is subject to the terms and conditions of the Certificate.
Refer to the Certificate of Coverage for a more complete listing of all 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 behavioral disorders, Worker's Compensation, military service-related conditions, or, unless otherwise
stated, dental services and vision correction services and supplies.
Benefits are subject to final approval by the Department of Insurance and therefore may be subject to change.
The UCR fee schedule for covered charges received on an out‐of‐network basis is either the allowed charge or actual charge. Allowed charge means a standard based on the 80th percentile of
the Prevailing Healthcare Charges System profile for New Jersey or other state when services or supplies are provided in such state. In paying benefits for prosthetic and orthotic appliances,
reimbursement will be at the same rate as reimbursement for such appliances under the Federal Medicare reimbursement schedule.
New Jersey Small Group Platinum PPO Flex $15/$45 - Non-gated, Liberty Network, Calendar Year
Representative Sample
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