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Oxford Freedom Network

450A Oxford Freedom Gold EPO

Oxford Freedom Network

Oxford Freedom Gold EPO — $25/$40 copays, $1,750 deductible, 20% coinsurance, Freedom network, no referrals. In-network only.

Monthly premiums

Member: $1,715.00/mo
Member & Children: $2,904.00/mo
Member & Spouse: $3,386.00/mo
Member & Family: $4,516.00/mo

Plan details

Deductible (Individual): $1,750
Deductible (Family): $3,500
Out-of-Pocket Max (Individual): $6,500
Out-of-Pocket Max (Family): $13,000
Coinsurance (In-Network): 20%
Primary Care Copay: $25
Specialist Copay: $40
Urgent Care Copay: $75
ER Copay: $500

Benefits

Deductible
$1,750 / $3,500
OON: Not Covered
Max Out of Pocket
$6,500 / $13,000
OON: Not Covered
Copay
$25 / $40 / $75
PCP / Specialist / Urgent Care
Coinsurance
20% after deductible
Emergency Room
$500 copay
In & out of network
Rx Coverage
$10 / $40 / $80
Generic / Preferred / Non-Preferred; $150 Rx ded
Pregnancy
Covered
Mental Health
Covered
$40 outpatient; 20% inpatient
Hospital Admission
20% coinsurance
After deductible
Referrals
Not Required
Dependents
To Age 26
Coverage
Nationwide
Oxford Freedom Network
Work Requirement
Work Required

Plan documents

Summary of Benefits and Coverageadmin_upload

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