Sample Plan Summary

OXFORD HEALTH INSURANCE, INC. EPO PLAN SUMMARY OF COVERAGE Freedom Network Sample Company Middle Plan BENEFIT In-Network FINANCIAL Deductible: Single $1,500 Family $3,000 Coinsurance 20% Maximum Out-of-Pocket: Single $6,000 (Including Deductible) Family $12,000 Financial Accumulation Period: Calendar Year 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 No Charge Infant and Pediatric Preventive Care No Charge OUTPATIENT CARE Primary Care Physician Office Visits $30 copay per visit Specialist Office Visits $50 copay per visit Virtual Visits No Charge Outpatient Surgery - Hospital Setting Deductible & 20% Coinsurance Outpatient Surgery - Freestanding Facility Deductible & 20% Coinsurance Laboratory Services - Hospital Setting No Charge Laboratory Services - Freestanding Facility No Charge (See your Certificate of Coverage for additional Lab details) Radiology Services - Hospital Setting Deductible & 20% Coinsurance Radiology Services - Freestanding Facility Deductible & 20% Coinsurance DIABETIC SUPPLIES AND MEDICATIONS Diabetic Supplies $30 copay Diabetic Medications $30 copay MRIs, MRAs, CT SCANS, AND PET SCANS Outpatient Hospital Services Deductible & 20% Coinsurance Freestanding Radiology Facility Deductible & 20% Coinsurance Sample HOSPITAL CARE Physician's and Surgeon's Services Deductible & 20% Coinsurance Semi-Private Room and Board Deductible & 20% Coinsurance All Drugs and Medication Deductible & 20% Coinsurance EMERGENCY CARE Ambulance Service when Medically Necessary No Charge At Hospital Emergency Room $500 copay per visit; waived if admitted (If member is admitted to the hospital, notification is required) Emergency Care in Urgi-Center $50 copay per visit MATERNITY CARE Routine Prenatal and Post-Natal Care No Charge Hospital Services for Mother and Child Deductible & 20% Coinsurance SKILLED NURSING FACILITY 30 Days per Calendar Year Deductible & 20% Coinsurance HOSPICE CARE Inpatient Care Deductible & 20% Coinsurance Home Hospice Care Visits $50 copay per visit HOME HEALTH CARE Home Care Visits - 40 visits per Calendar Year $50 copay per visit Physician House Calls $50 copay per visit SUBSTANCE USE DISORDER SERVICES Inpatient Rehabilitation Deductible & 20% Coinsurance Office Visits or Outpatient Rehabilitation $30 copay per visit Outpatient Partial Hospitalization No Charge MENTAL HEALTH CARE Inpatient Care Deductible & 20% Coinsurance Office Visits or Outpatient Care $50 copay per visit Outpatient Partial Hospitalization No Charge NYLG_EPO_01.01.23_v.1 1280471 January 1, 2023 Page 1 of 2

BENEFIT In-Network ALLERGY CARE Testing and Treatment $50 copay per visit CHIROPRACTIC CARE Chiropractic Care $50 copay per visit SHORT TERM REHAB OR HABILITATIVE SERVICES Inpatient limited to 60 Days per Calendar Year Deductible & 20% Coinsurance Outpatient limited to 60 combined PT/OT/ST Visits per Calendar $50 copay per visit Year DURABLE MEDICAL EQUIPMENT Unlimited Deductible & 20% Coinsurance (Precert required for items over $500) HEARING AIDS Limited to a single purchase (including repair/replacement) Deductible & 20% Coinsurance every 3 Years. MEDICAL SUPPLIES Medical Supplies when Medically Necessary Deductible & 20% Coinsurance EXERCISE FACILITY Subscriber $200 reimbursement per 6 month period Spouse/Dependents over age 13 $100 reimbursement per 6 month period INFERTILITY (Covers all services in compliance with the NY Infertility Mandate) Specialist Office Visits $50 copay per visit Inpatient Facility Services Deductible & 20% Coinsurance Outpatient Surgery - Hospital Setting Deductible & 20% Coinsurance Outpatient Surgery - Freestanding Facility Deductible & 20% Coinsurance OUTPATIENT PRESCRIPTION DRUGS - DEDUCTIBLE $100 Deductible (waived for Tier 1 Drugs) 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 $20 copay Tier 2 $60 copay Tier 3 $80 copay OUTPATIENT PRESCRIPTION DRUGS - MAIL ORDER Tier 1 $50.00 copay Tier 2 $150.00 copay Tier 3 $200.00 copay DEPENDENT ELIGIBILITY: Eligible dependents include the employee's spouse and dependent children until the child reaches age 26. Benefits discontinue at the end of the Month. Domestic Partners covered with proper documentation. Please be advised this sample summary of coverage is provided for informational purposes only. The information contained herein is subject to the approval of the New York Department of Insurance and Oxford home office approval as appropriate. 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, Workers' Compensation, military service-related conditions, or, unless otherwise stated, dental services and vision correction services and supplies. NYLG_EPO_01.01.23_v.1 1280471 January 1, 2023 Page 2 of 2