2024 Employee Benefit Guide - SSP - Yeled 11.8.23

EPO LIBERTY HIGH PLAN

PPO LIBERTY IN-NETWORK & OUT-OF-NETWORK PLAN

BENEFIT

IN-NETWORK ONLY

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible (Calendar Year)

Individual: None Family: None

Individual: $1,000 Family: $2,000

Individual: $2,000 Family: $4,000

Out-of-Pocket Maximum (Calendar Year)

Individual: $2,500 Family: $5,000

Individual: $2,500 Family: $5,000

Individual: $5,000 Family: $10,000

Coinsurance

You pay 0% Oxford pays 100%

You pay 0% Oxford pays 100%

You pay 30% Oxford pays 70%

Preventive Care Adult Preventive Care Infant and Pediatric Preventive Care

No Charge No Charge

No Charge No Charge

Not Covered Deductible & 30% Coinsurance

Outpatient Care Primary care physician office visits Specialist office visits Virtual Visits Outpatient Surgery - hospital/freestanding facility Laboratory - Preferred Lab Network Laboratory - Non-Preferred Lab Network Radiology - hospital/freestanding facility Complex Radiology hospital/freestanding facility (MRIs, MRAs, CT Scans, Pet Scans)

$30 copay $50 copay No Charge $250 copay No Charge $60 copay No Charge No Charge

$30 copay $50 copay No Charge No Charge after deductible No Charge 50% after deductible No Charge No Charge after deductible

Deductible & 30% Coinsurance Deductible & 30% Coinsurance In-Network Only Deductible & 30% Coinsurance

In-Network Only In-Network Only

Deductible & 30% Coinsurance Deductible & 30% Coinsurance

Inpatient Hospital Physicians and Surgeons Services Semi-Private Room and Board All Drugs and Medications Emergency Care Ambulance when medically necessary At hospital emergency room Urgent Care Maternity Care Prenatal and Post-natal care Hospital services for mother and child Mental Health/Substance Abuse Inpatient Outpatient Prescription Drugs Annual Deductible Retail Pharmacy Copay (30 day supply) Tier-1/Tier-2/Tier-3 Mail Order Copay (90 day supply) Tier-1/Tier-2/Tier-3

No Charge $500 copay per admission No Charge

No Charge after deductible No Charge after deductible No Charge after deductible

Deductible & 30% Coinsurance Deductible & 30% Coinsurance Deductible & 30% Coinsurance

No Charge $300 copay (waived if admitted) $50 copay

No Charge after deductible $300 copay $50 copay

Deductible & 30% Coinsurance $300 copay Deductible & 30% Coinsurance

No Charge $500 copay per admission

No Charge No Charge after deductible

Deductible & 30% Coinsurance Deductible & 30% Coinsurance

$500 copay per admission $50 /$30 copay

$50/$30 copay No Charge after deductible

Deductible & 30% Coinsurance Deductible & 30% Coinsurance

$50 per person (waived for Tier 1 drugs) $15/$35/$75

None

Not Applicable

$7/$20/$50

Not Covered

$37.50/$87.50/$187.50

Not Covered

$17.50/$50/$125

Dependent Age Limit: To age 26; benefits terminate at the end of the month in which the dependent turns 26

PRE-TAX MONTHLY CONTRIBUTIONS

Employee

$2,593.06

$3,151.58

Employee & Spouse

$5,445.42

$6,618.32

Employee & Child(ren)

$4,537.85

$5,515.27

Family

$7,908.82

$9,612.33

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.