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