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OXFORD HEALTH INSURANCE (NJ), INC
ACCESS PLAN
SUMMARY OF COVERAGE
Liberty Network
New Jersey League of Community Bankers |
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BENEFIT |
IN-NETWORK |
OUT-OF-NETWORK |
|
FINANCIAL |
|
|
|
Deductible |
Single
Family |
Not
Applicable
Not
Applicable |
$500
$1,000 |
|
Coinsurance
Maximum Out of Pocket::
(Including Deductible) |
Single
Family |
Not
Applicable
Not
Applicable
Not
Applicable |
30%
$3,500
$7,000 |
|
Maximum Lifetime Benefit per Member |
Unlimited |
Unlimited |
|
PREVENTATIVE CARE |
|
Physical Examination |
No
Charge |
Deductible and 30% Coinsurance |
|
$400
Out-of-Network Maximum per Calendar Year |
|
|
|
Routine Pediatric Care
$300
Out-of-Network Maximum per Calendar Year |
No
Charge |
30%
Coinsurance |
|
Immunizations (When Medically Necessary) |
No
Charge |
Deductible and 30% Coinsurance |
|
Preventative Dental for Children (Under Age 12) |
No
Charge |
No
Charge |
|
OUTPATIENT CARE |
|
Primary Care Physician Office Visits |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
Specialist Office Visits |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
Surgery** |
No
Charge |
Deductible and 30% Coinsurance |
|
Laboratory Services |
No
Charge |
Deductible and 30% Coinsurance |
|
Radiology Services ** |
No
Charge |
Deductible and 30% Coinsurance |
|
MRIs,
MRAs, CT Scans, PET Scans and Ultrasound** |
No
Charge |
Deductible and 30% Coinsurance |
|
ALLERGY CARE |
|
Initial Visit and all subsequent visits |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
HOSPITAL CARE |
|
|
|
Physician’s and Surgeon’s Services ** |
No
Charge |
Deductible and 30% Coinsurance |
|
Semi-private Room and Board ** |
No
Charge |
Deductible and 30% Coinsurance |
|
All
Drugs and Medication |
No
Charge |
Deductible and 30% Coinsurance |
|
EMERGENCY CARE |
|
Ambulance Service when Medically Necessary |
No
Charge |
No
Charge |
|
At
Hospital Emergency Room
(If
member is admitted to the hospital through the ER, notification is
required) |
$100
copay; waived if admitted |
100
copay; waived if admitted |
|
Emergency Care in Urgi-Center |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
MATERNITY CARE |
|
Prenatal and Post-natal Care ** |
$25
copay per initial visit |
Deductible and 30% Coinsurance |
|
Hospital Services for Mother and Child ** |
No
Charge |
Deductible and 30% Coinsurance |
|
SHORT
TERM REHABILITATION |
|
60
Consec. Inpatient Days per Condition per Lifetime ** |
No
Charge |
Deductible and 30% Coinsurance |
|
60
Outpatient Visits per Condition per Lifetime **
*(Pre-cert is needed after initial visit) |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
HOME
HEALTH CARE |
|
60
Home Care Visits ** |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
Physician House Calls |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
SKILLED NURSING FACILITY |
|
30
Days per Calendar Year ** |
No
Charge |
Deductible and 30% Coinsurance |
|
SUBSTANCE ABUSE |
|
7
Days of Inpatient Detox per Calendar Year ** |
No
Charge |
Deductible and 30% Coinsurance |
|
30
Days of Inpatient Rehab per Calendar Year ** |
No
Charge |
Deductible and 30% Coinsurance |
|
60
Outpatient Rehab Visits per Calendar Year ** |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
PRESCRIPTION DRUGS |
|
Generic Drugs **** |
$7
copayment |
Deductible and 30% Coinsurance |
|
Brand
Name Drugs **** |
$20
copayment |
Deductible and 30% Coinsurance |
|
(Includes Oral Contraceptives) |
|
|
|
MENTAL HEALTHCARE |
|
Inpatient Care ** |
|
|
|
Non-Biologically Based Conditions |
No
Charge |
Deductible and 30% Coinsurance |
|
30
Days per Calendar Year |
|
|
|
Biologically Based Conditions |
No
Charge |
Deductible and 30% Coinsurance |
|
Unlimited Days per Calendar Year |
|
|
|
Outpatient Care ** |
|
|
|
Non-Biologically Based Conditions |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
20
Visits per Calendar Year |
|
|
|
Biologically Based Conditions |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
Unlimited Visits per Calendar Year |
|
|
|
ALCOHOLISM |
|
Inpatient Care ** |
No
Charge |
Deductible and 30% Coinsurance |
|
Outpatient Care ** |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
CHIROPRACTIC CARE |
|
Chiropractic Care |
$25
copay per visit |
Deductible and 50% Coinsurance |
|
Maximum Payment of $500 per Calendar Year for Out-of-Network Services |
|
|
|
HOSPICE CARE
(180
days combined inpatient & outpatient) |
|
Inpatient Care ** |
No
Charge |
Deductible and 30% Coinsurance |
|
Outpatient Care ** |
No
Charge |
Deductible and 30% Coinsurance |
|
EXERCISE FACILITY |
|
Subscriber |
$100
reimbursement per 6 month period |
$100
reimbursement per 6 month period |
|
Spouse |
$50
reimbursement per 6 month period |
$50
reimbursement per 6 month period |
|
INFERTILITY TREATMENT |
|
Specialist Office Visits ** |
$25
copay per visit |
Deductible and 30% Coinsurance |
|
Outpatient Facility Services ** |
No
Charge |
Deductible and 30% Coinsurance |
|
Infertility Medications |
Members whose plan includes outpatient prescription drug coverage need
only pay the applicable Copayment when purchasing medications at a
network pharmacy. |
Deductible and 30% Coinsurance |
|
OTHER
ITEMS |
|
Medical Supplies, when Medically Necessary ** |
OUT-OF-NETWORK BENEFIT ONLY |
Deductible and 30% Coinsurance |
|
Durable Equipment, when Medically Necessary ** |
No
Charge |
Deductible and 30% Coinsurance |
|
$1,500 Maximum per Calendar Year |
|
|
|
Diabetic Supplies/Oral Agents |
Members whose plan includes outpatient prescription drug coverage need
only pay the applicable Copayment when purchasing medications at a
network pharmacy. |
Deductible and 30% Coinsurance |
|
DEPENDENT ELIGIBILITY:
Eligible dependents include the employee’s spouse and dependent children
until the child reaches age 23, or age 25 if a full time student.
Coverage ends at the end of the Calendar Year.
**
These services require precertification through Oxford. You must
call Oxford at 800-444-6222 at least 14 days in advance of request of
treatment to request precertification.
Mental health and substance abuse services can be precertified through
Oxford’s Behavioral Health Department by calling 1-800-201-6991.
****
Prescription medications ordered through the Mail Order Drug Program are
subject to 2 applicable retail pharmacy copays. The Prescription Drug
Benefit is based on a Per Contract Year Limit for any applicable
deductibles and/or maximum limits. |
|
Please Note: This sample summary of coverage is provided for
informational purposes only. The applicable Summary of Benefits will be
issued to be eligible enrolled members as part of the Certificate of
Coverage. Coverage is subject to the terms and conditions of the
Certificate. |
|
Refer
to your 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, hearing aids, or
unless otherwise stated, dental services and vision correction services
and supplies. |
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