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2010/2011 Plan Description: OXF-FRE-Access-PPO-1B-NY Product: PPO Network: Freedom Network Benefit In-Network General Plan Information

Lifetime Maximum Calendar Year Deductible - Individual Calendar Year Deductible - Family Coinsurance Calendar Year Out-of-Pocket Max - Individual Calendar Year Out-of-Pocket Max - Family Unlimited None None 100% Not Applicable Not Applicable

Provider: Oxford Health Plans Member Services Phone #: 1-800-444-6222 Plan Website Address: https://www.oxfordhealth.com Out-of-Network
Unlimited $750 $1,875 80% $2,750 (includes deductible) $6,875 (includes deductible)

Office Visits
Primary Care Physician Visit Specialist Visit Specialist Referral Required $15 copay per visit $30 copay per visit No Covered at 80% after deductible Covered at 80% after deductible No

Hospital Care
Hospital Care - Inpatient Hospital Care - Outpatient $500 copay per continuous confinement $250 copay Covered at 80% after deductible Covered at 80% after deductible

Emergency Care
Emergency Room (In-Area) Urgent Care Facility Ambulance $100 copay per visit, waived if admitted $30 copay per visit Covered at 100% when medically necessary $100 copay per visit, waived if admitted Covered at 80% after deductible Covered at 100% when medically necessary

Prescription
Tier 1 Retail Tier 2 Retail Tier 3 Retail Tier 4 Retail Mail Order Medicare Part D Compatible $15 copay $25 copay, $50 deductible applies $50 copay, $50 deductible applies Not Applicable $30/$50/$100 copay ($50 deductible applies to tier 2 & 3) Yes Covered only at participating pharmacies Covered only at participating pharmacies Covered only at participating pharmacies Not Applicable Covered only at participating pharmacies

Yes

Maternity Care
Pregnancy and Maternity Care (Pre-Natal Care) $15 copay per initial visit. $500 copay per hospital admission Covered at 100% at participating laboratories only. Preventative x-rays not covered Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 80% after deductible

Preventive Care
Diagnostic X-Ray Lab Physical Examinations Prostate Screening Gynecology Exam Mammograms Well Baby Care and Immunizations Covered at 80% after deductible. Preventative x-rays not covered Covered at 80% after deductible. Maximum payment of $300 per calendar year Covered at 80% after deductible. Maximum payment of $300 per calendar year Covered at 80% after deductible. Maximum payment of $300 per calendar year Covered at 80% after deductible Covered at 80% after deductible. Maximum payment of $300 per calendar year Covered at 80% after deductible Covered at 80% after deductible Covered at 80% after deductible Covered at 80% after deductible Covered at 80% after deductible Covered at 80% after deductible

Other Services
Chiropractic Care $30 copay per visit. $500 copay per continuous confinement $500 copay per continuous confinement $30 copay per visit $500 copay per continuous confinement $30 copay per visit

Substance Abuse
Inpatient Detoxification Substance Abuse - Inpatient Substance Abuse - Outpatient

Mental Health
Mental Health - Inpatient Mental Health - Outpatient

This benefit summary has been prepared by a licensed Insurance carrier or broker based on documents provided by the applicable licensed Insurance carrier. Please refer to the Plan Document and Certificate of Coverage (COC) for terms and conditions of all benefits. Benefits may require pre-certification in order to avoid a reduction in benefits or denial of coverage. The insured should contact the carrier at the phone number indicated on this summary or refer to the COC for further details prior to seeking treatment. If there is any conflict between this benefit summary and the Plan Document or COC, the Plan Document and COC govern. This health insurance plan is part of a large group health plan, as such Medicare is the secondary payer for any insured member that is enrolled in Medicare and this plan. If eligible for Medicare due to ESRD, Medicare becomes primary payer after thirty months of Medicare eligibility. If member is a COBRA participant, Medicare is the primary payer.

ADP TotalSource Employee Service Center (800) 554-1802

sum954-0610-S

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