PR - 4.2024 Employee Benefits Guide (FINAL)

EPO METRO LOW PLAN FOR NEW JERSEY AND NEW YORK EMPLOYEES ONLY

BENEFIT

IN-NETWORK ONLY

Annual Deductible

Individual:

$1,250 $2,500 $3,000 $6,000

Family:

Out-of-Pocket Maximum Including deductible

Individual:

Family:

Coinsurance

Oxford 80% Employee 20%

Preventive Care

Covered 100% deductible waived

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

$25 Copay $40 Copay

Covered 100% deductible waived $150 copay deductible waived $75 copay deductible waived

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

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

20% after deductible 20% after deductible 20% after deductible Covered 100% 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

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

$100 copay then 20% after deductible $40 copay deductible waived

Chiropractic Care

$30 copay

Prescription Drug Deductible

$100 copay; waived for Tier 1 Drugs

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

$10 copay $40 copay $70 copay

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

$20 copay $80 copay $140 copay

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.

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