2024 Employee Benefit Guide - Salaried - Yeled 11.3.23

HSA EPO LIBERTY PLAN

EPO LIBERTY LOW PLAN

BENEFIT

IN-NETWORK ONLY

IN-NETWORK ONLY

Annual Deductible (Calendar Year)

Individual: $3;000 Family: $6,000* *If you have a family contract, the entire family Deductible must be satisfied before coverage under this Plan is available.

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

Out-of-Pocket Maximum (Calendar Year)

Individual: $6,350 Family: $12,700

Individual: $6,350 Family: $12,700

Coinsurance

You pay 50% Oxford pays 50%

You pay 40% Oxford pays 60%

Preventive Care Adult Preventive Care Infant and Pediatric Preventive Care

No Charge No Charge

No Charge No Charge

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)

Deductible & 50% Coinsurance Deductible & 50% Coinsurance No Charge (Not subject to deductible)

$30 copay $50 copay No Charge Deductible and 40% coinsurance No Charge Deductible and 50% Coinsurance Deductible and 40% Coinsurance Deductible and 40% coinsurance

Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% 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

Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance

Deductible and 40% coinsurance Deductible and 40% coinsurance Deductible and 40% coinsurance

Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance

No Charge Deductible and 40% coinsurance $50 copay

No Charge Deductible & 50% Coinsurance

No Charge Deductible and 40% coinsurance

Deductible & 50% Coinsurance Deductible & 50% Coinsurance

Deductible and 40% coinsurance $50/$30 copay

Subject to the plan deductible, then copays apply

$50 per person (waived for Tier 1 drugs)

$15/$35/$75

$15/$35/$75

$37.50/$87.50/$187.50

$37.50/$87.50/$187.50

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

PRE-TAX SEMI MONTHLY CONTRIBUTIONS

0 TO 2 YEARS

2+ YEARS**

0 TO 2 YEARS

2+ YEARS**

Employee

$128.95

$128.95

$441.93

$441.93

Employee & Spouse*

$392.64

$203.09

$1,049.90

$860.35

Employee & Child(ren)*

$372.33

$203.09

$920.05

$750.81

Family*

$747.23

$452.27

$1,701.84

$1,406.88

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.