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Oxford Liberty Network

450A Oxford Liberty Silver EPO

Oxford Liberty Network

Oxford Liberty Silver EPO — $30/$60 copays, $4,500 deductible, 50% coinsurance, Liberty network, no referrals. In-network only.

Monthly premiums

Member: $1,433.00/mo
Member & Children: $2,436.00/mo
Member & Spouse: $2,825.00/mo
Member & Family: $3,754.00/mo

Plan details

Deductible (Individual): $4,500
Deductible (Family): $9,000
Out-of-Pocket Max (Individual): $9,200
Out-of-Pocket Max (Family): $18,400
Coinsurance (In-Network): 50%
Primary Care Copay: $30
Specialist Copay: $60
Urgent Care Copay: $100

Benefits

Deductible
$4,500 / $9,000
OON: Not Covered
Max Out of Pocket
$9,200 / $18,400
OON: Not Covered
Copay
$30 / $60 / $100
PCP / Specialist / Urgent Care
Coinsurance
50% after deductible
Emergency Room
50% coinsurance
After deductible
Rx Coverage
$10 / $50 / $90
Generic / Preferred / Non-Preferred; $200 Rx ded
Pregnancy
Covered
Mental Health
Covered
$60 outpatient; 50% inpatient
Hospital Admission
50% coinsurance
After deductible
Referrals
Not Required
Dependents
To Age 26
Coverage
Nationwide
Oxford Liberty Network
Work Requirement
Work Required

Plan documents

Summary of Benefits and Coverageadmin_upload

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