OXFORD Individual Oxford Metro Network
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1 OXFORD Individual /18/2016 Oxford Metro Network In-Network Only / Referrals Required PLATINUM HMO GOLD $600 HMO SILVER $2000 HMO BRONZE $3500 HMO BRONZE $4000 HMO HSA (***Preferred Generics) $10/$30/$60 $10/$35/$70 $10/$35/$70 $10/$35/$70 After Plan Deductible $10/$35/$70 After Plan Deductible **Deductible Ind/Fam None $600/$1,200 $2,000/$4,000 $3,500/$7,000 $4,000/$8,000 **Co-Insurance 10% 20% 30% 50% 50% **Out-of-Pocket Ind/Fam $2000/$4000 $4,000/$8,000 $5,500/$11,000 $6,850/$13,700 $6,450/$12,900 Office Co-pay $15 $25 $30 50% 50% Specialist Co-pay $35 $40 $50 50% 50% Urgent Care $55 $60 $70 50% 50% Hospital In-Patient $500 $1,000 $1,500 Copay/visit 50% 50% Outpatient Facility $100 $100 $100 50% 50% Emergency Room $100 $150 Copay/visit $150 Copay/visit after Deductible 50% 50% Single $ $ $ $ $ Couple $1, $1, $1, $ $ Parent/Child(ren) $1, $1, $ $ $ Family $2, $1, $1, $1, $1, *** NOTE: Preferred Generics : You must pay difference in cost for brands if a generic equivalent is available. Premium rates and plan designs are not yet finalized and are subject to approval by regulators
2 CareConnect Individual 2016 North Shore LIJ Insurance Company - NYC/Westchester 11/6/2015 rev. CareConnect Network Tradition PLATINUM EPO Tradition GOLD EPO Tradition SILVER EPO (CVS/Caremark) $15 / $35 / $75 ($100 Rx Deduct. waived for T1) $10 gen/$50 brand/ *50% co-insurance non-pref brands (up to $250 max) $10 gen/$50 brand/ *50% co-insurance non-pref brands (up to $250 max) **Deductible Ind/Fam N/A $1,000/$2,000 $4,000/$8,000 **Co-Insurance N/A 10% 20% **Out-of-Pocket Ind/Fam $1,000/$2,000 $3,000/$6,000 $6,600/$13,200 Office Co-pay $30 $30 $40 Specialist Co-pay $30 $50 $60 Urgent Care $30 $50 $60 Hospital In-Patient $500 10% After Deductible 20% After Deductible Outpatient Facility $200 10% After Deductible $350 Emergency Room $200 $200 $350 Single $ $ $ Couple $1, $ $ Parent/Child(ren) $ $ $ Family $1, $1, $1, The Tradition difference With Tradition Plans the plan deductible does NOT apply to doctor visits, so members are only responsible for the copay. ** IMPORTANT: The plan DEDUCTIBLE applies to all Inpatient/OutPatient Hospital and Ambulance benefits. The rates and benefits in this report are not valid without approval from the Insurance Carriers
3 CareConnect Individual 2016 North Short LIJ Insurance Company - NYC/Westchester 10/30/2015 CareConnect Network Standard PLATINUM EPO Standard GOLD EPO Standard SILVER EPO Standard BRONZE EPO (CVS/Caremark) $10/$30/$60 $10/$35/$70 $10/$35/$70 $10/$35/$70 after Plan Deductible **Deductible Ind/Fam N/A $600/$1,200 $2,000/$4,000 $3,500/$7,000 **Co-Insurance 10% on DME & children's eyeglasses 20% on DME & children's eyeglasses 30% on DME & children's eyeglasses 50% **Out-of-Pocket Ind/Fam $2000/$4000 $4,000/$8,000 $5,500/$11,000 $6,850/$13,700 Office Co-pay $15 $25 $30 50% Specialist Co-pay $35 $40 $50 50% Urgent Care $55 $60 $70 50% Hospital In-Patient $500 $1,000 $1,500 50% Outpatient Facility $100 $100 $100 50% Emergency Room $100 $150 $150 50% Single $ $ $ $ Couple $1, $ $ $ Parent/Child(ren) $ $ $ $ Family $1, $1, $1, $ The rates and benefits in this report are not valid without approval from the Insurance Carriers
4 Oscar Network Classic 10/29/2015 PLATINUM GOLD SILVER BRONZE **Deductible Ind/Fam **Co-Insurance **Out-of-Pocket Ind/Fam Office Co-pay (3 Free) Specialist Co-pay Urgent Care Hospital In-Patient Outpatient facility Emergency Room Single Couple Parent/Child(ren) Family $0/$50/$150 $0/$50/$150 $0/$50/$150 $0 After Plan Deductible N/A $1,000/$2,000 $4,500/$9,000 $6,850/$13,700 N/A N/A N/A N/A $2000/$4000 $4,000/$8,000 $5,500/$11,000 $6,850/$13,700 $15 $25 After Deductible $30 After Deductible $0 After Deductible $35 $40 After Deductible $50 After Deductible $0 After Deductible $35 $40 After Deductible $50 After Deductible $0 After Deductible $500 $1,000 After Deductible $1,500 After Deductible $0 After Deductible $100 $100 After Deductible $100 After Deductible $0 After Deductible $100 $150 After Deductible $150 After Deductible $0 After Deductible $ $ $ $ $1, $1, $ $ $1, $ $ $ $1, $1, $1, $1, The rates and benefits in this report are not valid without approval from the Insurance carriers
5 Oscar Network Market 10/30/2015 PLATINUM GOLD SILVER BRONZE SECURE $10/$30/$60 $10/$35/$70 $10/$35/$70 $10/$35/$70 After Plan Deductible **Deductible Ind/Fam N/A $600/$1,200 $2,000/$4,000 $3,500/$7,000 $6,850 **Out-of-Pocket Ind/Fam $2000/$4000 $4,000/$8,000 $5,500/$11,000 $6,850/$13,700 $6,850 Office Co-pay $15 $25 After deductible $30 After deductible 50% After deductible 3 for $0 Specialist Co-pay $35 $40 After deductible $50 After deductible 50% After deductible $0 After deductible Urgent Care $55 $60 After deductible $70 After deductible 50% After deductible $0 After deductible Inpatient Facility $500 $1,000 After deductible $1,500 After deductible 50% After deductible $0 After deductible Outpatient Facility $100 $100 After deductible $100 After deductible 50% After deductible $0 After deductible Emergency Room $100 $150 After deductible $150 After deductible 50% After deductible $0 After deductible Single $ $ $ $ $ Couple $1, $1, $ $ N/A Parent/Child(ren) $1, $ $ $ N/A Family $1, $1, $1, $1, N/A The rates and benefits in this report are not valid without approval from the Insurance carriers.
6 11/17/2015r Oscar Network SIMPLE Platinum Gold Silver Bronze Generics - $0 Preferred/Non-Preferred $0 Generics - $0 Preferred/Non-Preferred $0 Generics - $0 Preferred/Non-Preferred $0 Generics - $20 Generic/ Preferred/Non-Preferred ALL **Deductible Ind/Fam $1,000/$2,000 $3,000/$6,000 $5,900/$11,800 **Co-Insurance N/A N/A N/A **Out-of-Pocket Ind/Fam $1,000/$2,000 $3,000/$6,000 $5,900/$11,800 Office Co-pay $0 $0 $0 $6,850/$13,700 N/A $6,850/$13,700 2 at $20, then $0 after Deductible Specialist Co-pay Urgent Care Hospital In-Patient Outpatient facility Emergency Room Single $ $ $ $ Couple $1, $1, $ $ Parent/Child(ren) $1, $ $ $ Family $1, $1, $1, $1, The rates and benefits in this report are not valid without approval from the Insurance carriers
7 Oscar Network Simple + 11/3/2015 Platinum Gold Silver Generics - $0 / Preferred $50 / ALL Generics - $0 / Preferred $50 / ALL Generics - $0 / Preferred $50 / ALL **Deductible Ind/Fam $1,000/$2,000 $3,000/$6,000 $5,900/$11,800 **Co-Insurance N/A N/A N/A **Out-of-Pocket Ind/Fam $1,000/$2,000 $3,000/$6,000 $5,900/$11,800 Office Co-pay $0 $0 $0 Specialist Co-pay Urgent Care Hospital In-Patient Outpatient facility Emergency Room Single $ $ $ Couple $1, $1, $ Parent/Child(ren) $1, $ $ Family $1, $1, $1, The rates and benefits in this report are not valid without approval from the Insurance carriers
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