PLANS |
PLAN #1 Liberty Plan Direct (Liberty Network) |
PLAN #2 Oxford Exclusive Metro (Liberty Network) |
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PLAN #3 Oxford Direct HSA (Freedom Network) |
PLAN #4 Oxford HSA Exclusive (Freedom Network) |
| MONTHLY PREMIUM FOR MANHATTAN, RICHMOND, BRONX, AND SUFFOLK COUNTIES |
Single: $649.59 Husband & Wife: $1429.10 Family: $2060.03 **Mental Health Riders Available** |
Single: $524.19 Husband & Wife: $1153.22 Family: $1631.87 **Mental Health Riders Available** |
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Single: $551.29 Husband & Wife: $1212.84 Family: $1749.41 **Mental Health Riders Available** |
Single: $555.37 Husband & Wife: $1221.81 Family: $1728.53 **Mental Health Riders Available** |
MONTHLY PREMIUM FOR KINGS, QUEENS, AND NASSAU COUNTIES |
Single: $665.54 Parent & Child(ren): $1235.62 Husband & Wife: $1464.19 Family: $2110.44 **Mental Health Riders Available** |
Single: $537.10 Parent & Child(ren): $997.75 Husband & Wife: $1181.62 Family: $1671.89 **Mental Health Riders Available** |
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Single: $567.82 Parent & Child(ren): $1054.84 Husband & Wife: $1249.20 Family: $1801.64 **Mental Health Riders Available** |
Single: $572.03 Parent & Child(ren): $1062.37 Husband & Wife: $1258.472 Family: $1780.17 **Mental Health Riders Available** |
DEDUCTIBLE FOR IN-NETWORK OR OUT-OF-NETWORK |
$2000 Single $5000 Family |
$2000 Single $5000 Family |
$2850 Single $5700 Family |
$2000 Single $4000 Family |
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CO-INSURANCE FOR IN-NETWORK |
20% After Deductible Out-of-Pocket Maximum (Incl. Ded.): $4000 Single $10000 Family |
10% After Deductible Out-of-Pocket Maximum (Incl. Ded.): $3000 Single $7500 Family |
10% After Deductible Out-of-Pocket Maximum (Incl. Ded.): $3850 Single $7700 Family |
100% After Deductible Out-of-Pocket Maximum: $2000 Single $4000 Family |
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CO-INSURANCE FOR OUT-OF-NETWORK |
40% After Deductible (Ins Co only covers 70% of UCR rate) Out-of-Pocket Maximum (Incl. Ded.): $15000 Family **Lifetime Max: $1 Million** |
NO OUT OF NETWORK OPTION WITH THIS PLAN (IN NETWORK ONLY!) |
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10% After Deductible (Ins Co only covers 70% of UCR rate) Out-of-Pocket Maximum (Incl. Ded.): $11700 Family **Lifetime Max: NONE** |
NO OUT OF NETWORK OPTION WITH THIS PLAN (IN NETWORK ONLY!) |
| OFFICE VISITS | In-Network: $30 Copay for PCP, $50 Copay for Specialist Out-of-Network: Subject to Deductible & 40% Co-Insurance |
$25 Copay for PCP, $50 Copay for Specialist | In-Network: Subject to Deductible and 10% Co-Insurance Out-of-Network: Subject to Deductible & 30% Co-Insurance |
$0 after Deductible | |
| EMERGENCY ROOM | In-Network: $200 Copay Out-of-Network: Subject to Deductible & 20% Co-Insurance |
$200 Copay | In-Network: Subject to Deductible & 10% Co-Insurance Out-of-Network: Subject to Deductible & 10% Co-Insurance |
$0 after Deductible | |
HOSPITAL & PHYSICIAN SERVICES |
In-Network: Subject to Deductible & 20% Co-Insurance Out-of-Network: Subject to Deductible & 40% Co-Insurance |
IN NETWORK ONLY: Subject to Deductible & 10% Co-Insurance | In-Network: Subject to Deductible & 10% Co-Insurance Out-of-Network: Subject to Deductible & 30% Co-Insurance |
$0 after Deductible | |
Rx DRUG CARD |
$100 Annual Deductible, then: $15 Generic 50% off Name-Brand Formulary |
$100 Annual Deductible, then: $15 Generic 50% off Name-Brand Formulary |
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Subject to Deductible, then: $15 Generic 50% off Name-Brand Formulary |
Subject to Deductible, then: $15 Generic 50% off Name-Brand Formulary |
| DEPENDENT CHILDREN Dependent Age 29 Rider Available |
Covered age 26 or Age 29 Rider: Parent/Child(ren): $68.71 Family: $73.62 |
Covered until age 26 or Age 29 Rider: Parent/Child(ren): $55.70 Family: $56.63 |
Covered age 26 or Age 29 Rider: Parent/Child(ren): $68.71 Family: $73.62 |
Covered until age 26 or Age 29 Rider: Parent/Child(ren): $55.70 Family: $56.63 |
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Rates include administrative fees and are subject to Benefits are for comparative purposes only. Actual rate & benefit info and details must come directly from the insurance carrier. This is only a summary of benefits. You will receive full details of coverage contained in the policy received directly from Insurance Company. If there is any conflict between the contents of this document/website and the policy from the Insurance Company, the Policy will govern in all cases.This list is for reference only. From time to time, the status of a physician or provider may change, meaning that a new physician or provider may be added or a current physician or provider may either leave the network or decline to accept new patients. As a result, you MUST call the physician or provider to confirm participation with the appropriate Oxford network (Liberty or Freedom).
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