UL - 2023-24 Benefits Guide (FINAL) SP

FREEDOM NETWORK EPO PLAN (NY/NJ) CHOICE NETWORK EPO PLAN (CA & any States outside Tri-State area)

BENEFIT

Annual Deductible (Policy Year)

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

Out-of-Pocket Maximum (Policy Year)

Individual: $4,500; Family: $9,000

Coinsurance

Employee Pays 20%/Oxford Pays 80%

Preventive Care Adult Preventive Care Adult Annual Physical Exam Well-Child Care In-Patient Hospital Care Physician and Surgeons Services Semi-Private Room and Board

No Charge No Charge No Charge

Deductible & Coinsurance Deductible & Coinsurance

Outpatient Care Primary care physician office visits Specialist office visits Virtual Visits Outpatient facility surgery (Hospital Setting & Free-Standing Facility) Outpatient Laboratory Services (Hospital Setting & Free-Standing Facility) Outpatient Radiology Emergency Care Ambulance when medically necessary At hospital emergency room (Waived if Admitted) Urgent Care Maternity Care Prenatal and Post-natal care Hospital services for mother and child

$30 Copay $50 Copay No Charge Deductible and Coinsurance

No Charge

Deductible and Coinsurance

(Hospital Setting & Freestanding Facility) MRI’s/MRA’s/CT Scans and PET Scans (Outpatient Hospital Services & Freestanding Radiology Facility)

Deductible and Coinsurance

No Charge $150 Copay Per Admission

$50 Copay

No Charge Deductible & Coinsurance

Mental Health Inpatient Outpatient

Deductible & Coinsurance $50 Copay

Prescription Drug Deductible Retail Pharmacy (30 day supply) Generic/Preferred Brand/Non-Preferred Brand Mail Order (30 day supply) Generic/Preferred Brand/Non-Preferred Brand

$10/$25/$50

$25/$62.50/$125

Bi-Weekly Contributions Employee Only Employee + Spouse Employee + Children Employee + Family

$73.00 $153.00 $128.00 $222.00

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