OXFORD HEALTH INSURANCE, INC. New York Small Group Platinum Oxford Standard EPO Plan ($15/$35)- Gated SUMMARY OF COVERAGE Representative Sample Liberty Network BENEFIT FINANCIAL Deductible: Single Family Coinsurance Single Maximum Out-Of-Pocket: (Including Deductible) Family Financial Accumulation Period: Out-of-Network Reimbursement: IN-NETWORK OUT-OF-NETWORK None None 10% $2,000 $4,000 Calendar Year Not Applicable Not Covered Not Covered Not Covered Not Covered Not Covered Not Applicable Not Applicable 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 Infant and Pediatric Preventive Care Preventive Dental for Children (Up to age 19)** Pediatric Vision Exam (Up to age 19) Pediatric Vision Hardware (Up to age 19) No Charge No Charge $15 copay per visit $15 copay per visit 10% Coinsurance Not Covered Not Covered Not Covered Not Covered Not Covered OUTPATIENT CARE Primary Care Physician Office Visits Specialist Office Visits* Outpatient Surgery - Hospital Setting** Outpatient Surgery - Freestanding Facility** Laboratory Services** Radiology Services** $15 copay per visit $35 copay per visit $100 copay per visit $100 copay per visit $35 copay per service $35 copay per service Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered MRIs, MRAs, CT SCANS, AND PET SCANS Outpatient Hospital Services** Freestanding Radiology Facility** $35 copay per service $35 copay per service Not Covered Not Covered HOSPITAL CARE Physician's and Surgeon's Services ** Semi-Private Room and Board ** All Drugs and Medication $100 copay per visit $500 copay per admission No Charge Not Covered Not Covered Not Covered $100 copay $100 copay per visit $100 copay $100 copay per visit $55 copay per visit Not Covered MATERNITY CARE Prenatal and Post-Natal Care ** Hospital Services for Mother and Child ** No Charge $500 copay per admission Not Covered Not Covered SKILLED NURSING FACILITY 200 days per Contract Year.** $500 copay per admission Not Covered $500 copay per admission $15 copay per visit Not Covered Not Covered HOME HEALTH CARE Home Care Visits - 40 visits per Calendar Year.** Physician House Calls $15 copay per visit $35 copay per visit Not Covered Not Covered SUBSTANCE USE DISORDER SERVICES Inpatient Rehabilitation** Outpatient Rehabilitation $500 copay per admission $15 copay per visit Not Covered Not Covered EMERGENCY CARE Ambulance Service When Medically Necessary** At Hospital Emergency Room (waived if admitted) (If member is admitted to the hospital, notification is required.) Emergency Care in Urgi-Center HOSPICE CARE Inpatient Care** Home Hospice - 210 days combined (Inpatient & Home) per Calendar Year. New York Small Group Platinum Oxford Standard EPO Plan ($15/$35)- Liberty Network, Gated Representative Sample Page 1 of 2 BENEFIT IN-NETWORK OUT-OF-NETWORK MENTAL HEALTH CARE Inpatient Care** Outpatient Visits $500 copay per admission $15 copay per visit Not Covered Not Covered ALLERGY CARE Testing and Treatment** $35 copay per visit Not Covered ALTERNATIVE MEDICINE Chiropractic Care - Unlimited Visits** $35 copay per visit Not Covered SHORT TERM REHAB & HABILITATIVE SERVICES Inpatient limited to 60 days per Calendar Year.** Outpatient limited to 60 visits per Calendar Year (combined with Habilitative Service).** $500 copay per admission $25 copay per visit Not Covered Not Covered DURABLE MEDICAL EQUIPMENT Durable Medical Equipment - Unlimited.** Precertification required for items over $500 10% Coinsurance Not Covered 10% Coinsurance Not Covered 10% Coinsurance Not Covered $200 reimbursement per 6 month period $100 reimbursement per 6 month period Not Covered Not Covered MEDICAL SUPPLIES Medical Supplies When Medically Necessary** HEARING AIDS Hearing Aids - Coverage is limited to a single purchase (including repair/replacement) per hearing impaired ear every three years. EXERCISE FACILITY Subscriber Spouse 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 $10 copay Tier 2 $30 copay Tier 3 $60 copay Not Covered Not Covered Not Covered OUTPATIENT PRESCRIPTION DRUGS - MAIL ORDER Tier 1 Tier 2 Tier 3 Not Covered Not Covered Not Covered $25 copay $75 copay $150 copay DEPENDENT ELIGIBILITY: Eligible dependents include the employee's spouse and dependent children until the child reaches age 26. *Visits to an Oxford participating Specialist require an authorized referral from the member's Primary Care Physician. **These services require precertification through Oxford. Members must call Oxford at 1-800-444-6222 at least 14 days in advance of request of treatment to request precertification. **Mental health and substance use disorder services can be precertified through Oxford's Behavioral Health Department by calling 1-800-201-6991. **Precertification is required for Pediatric Orthodontia services only Please Note: This sample summary of coverage is provided for informational purposes only. 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, Worker's Compensation, military service-related conditions, or, unless otherwise stated, dental services and vision correction services and supplies. Benefits are subject to final approval by the Department of Insurance and therefore may be subject to change. New York Small Group Platinum Oxford Standard EPO Plan ($15/$35)- Liberty Network, Gated Representative Sample Page 2 of 2