PR - 4.2024 Employee Benefits Guide (FINAL)

LIBERTY DIRECT HIGH PLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible

Individual:

$1,000 $2,000 $5,000 $10,000

Individual:

$2,000 $4,000 $10,000 $20,000

Family:

Family:

Out-of-Pocket Maximum Including deductible

Individual:

Individual:

Family:

Family:

Coinsurance

Oxford 80% Employee 20%

Oxford 60% Employee 40%

Preventive Care

Covered 100% deductible waived

40% after deductible

Outpatient Care PCP copay office visits Specialist copay office visits Virtual Care Outpatient Surgery (Hospital Setting) Outpatient Surgery (Freestanding Facility)

40% after deductible 40% after deductible In-Network Only 40% after deductible 40% after deductible

$25 copay $40 copay Covered 100% deductible waived

20% after deductible 20% after deductible

Laboratory Services Designated Laboratory Services Non-Designated Laboratory Services (Hospital Setting) Non-Designated Laboratory Services (Freestanding Facility )

Covered 100% deductible waived 50% after deductible 50% after deductible

40% after deductible 40% after deductible 40% after deductible

Radiology Services Radiology Services (Hospital Setting) Radiology Services (Freestanding Facility)

20% after deductible 20% after deductible 20% after deductible 20% after deductible

40% after deductible 40% after deductible 40% after deductible 40% after deductible

Advanced Radiology - MRI, MRA, CAT & Pet Scan (Hospital Setting) Advanced Radiology - MRI, MRA, CAT & Pet Scan (Freestanding Facility)

Inpatient Hospital Care

20% after deductible

40% after deductible

Emergency Care Hospital Emergency Room (waived if admitted) Urgent Care

20% after deductible $40 copay

20% after deductible 40% after deductible

Chiropractic Care

$30 copay

50% after deductible

Prescription Drug Deductible

None

N/A

Retail Drug Program (30 day supply) Tier 1 Tier 2 Tier 3

$25 copay $50 copay $75 copay

In-Network Only

Mail Order (90 day supply) Tier 1 Tier 2 Tier 3

$50 copay $100 copay $150 copay

In-Network Only

Please note: If you are living outside of the Tri-State area (NJ/NY/CT), please utilize the Oxford Liberty with Core Network.

6 QUESTIONS? Call Bene fi tsVIP at 866.293.9736 For addi Ɵ onal plan informa Ɵ on, please refer to your detailed plan design. In the event of a discrepancy, the carrier Plan Document shall prevail.