PLAN

PLAN #1

Liberty Plan Direct (Liberty Network)

PLAN #2

Oxford Exclusive Metro (Liberty Network)

Oxford Exclusive Metro (Liberty Network)
 

NO DEDUCTIBLES!

PLAN #3

Oxford Direct  HSA (Freedom Network)

 PLAN #4

Oxford HSA Exclusive (Freedom Network)

FOR MANHATTAN, RICHMOND, BRONX, AND SUFFOLK COUNTIES

Parent & Child(ren): $676.79

Husband & Wife: $804.83

Family: $1134.06

**Mental Heath Riders Available**

Parent & Child(ren): $602.17

Husband & Wife: $716.09

Family: $1009.03

**Mental Heath Riders Available**

Parent & Child(ren): $721.12

Husband & Wife: $857.54

Family: $1208.36

**Mental Heath Riders Available**

Parent & Child(ren): $564.87

Husband & Wife: $671.74

Family: $946.54

**Mental Heath Riders Available**

Parent & Child(ren): $591.27

Husband & Wife: $703.13

Family: $990.78

**Mental Heath Riders Available**

MONTHLY PREMIUM 

FOR KINGS, QUEENS, AND NASSAU COUNTIES

Single: $374.64

Parent & Child(ren): $693.08

Husband & Wife: $824.21

Family: $1161.37

**Mental Health Riders Available**

Single: $333.42

Parent & Child(ren): $616.84

Husband & Wife: $733.53

Family: $1033.60

**Mental Heath Riders Available**

Single: $399.64

Parent & Child(ren): $739.34

Husband & Wife: $879.20

Family: $1238.87

**Mental Heath Riders Available**

Single: $314.50

Parent & Child(ren): $581.83

Husband & Wife: $691.91

Family: $974.96

**Mental Heath Riders Available**

Single: $329.20

Parent & Child(ren): $609.02

Husband & Wife: $724.24

Family: $1020.52

**Mental Heath Riders Available**

DEDUCTIBLE FOR

 IN-NETWORK OR

OUT-OF-NETWORK

$2000 Single

$4000 Family

$2000 Single

$4000 Family

N/A

$2850 Single

$5700 Family

$2000 Single

$4000 Family

CO-INSURANCE FOR

IN-NETWORK

20% After Deductible

Out-of-Pocket Maximum (Incl. Ded.):

$4000 Single

$8000 Family

10% After Deductible

Out-of-Pocket Maximum (Incl. Ded.):

$3000 Single

$6000 Family

N/A

10% After Deductible

Out-of-Pocket Maximum (Incl. Ded.):

$3850 Single

$7700 Family

100% After Deductible

Out-of-Pocket Maximum:

$2000 Single

$4000 Family

CO-INSURANCE FOR

OUT-OF-NETWORK

40% After Deductible

(Ins Co only covers 70% of UCR rate)

Out-of-Pocket Maximum (Incl. Ded.):
$6000 Single

$12000 Family

**Lifetime Max: $1 Million**

NO OUT OF NETWORK OPTION WITH THIS PLAN

(IN NETWORK ONLY!)

NO OUT OF NETWORK OPTION WITH THIS PLAN

(IN NETWORK ONLY!)

10% After Deductible

(Ins Co only covers 70% of UCR rate)

Out-of-Pocket Maximum (Incl. Ded.):
$5850 Single

$11700 Family

**Lifetime Max: NONE** 

NO OUT OF NETWORK OPTION WITH THIS PLAN

(IN NETWORK ONLY!)

 
OFFICE VISITS

 
In-Network: $30 Copay for PCP, $50 Copay for Specialist

Out-of-Network: Subject to Deductible & 40% Co-Insurance

 
$25 Copay for PCP, $50 Copay for Specialist

$25 Copay for PCP, $50 Copay for Specialist

 
In-Network: Subject to Deductible and 10% Co-Insurance

Out-of-Network: Subject to Deductible & 30% Co-Insurance

$0 after Deductible

 
EMERGENCY ROOM

 
In-Network: $100 Copay

Out-of-Network: Subject to Deductible & 20% Co-Insurance

 
$75 Copay

$75 Copay

 
In-Network: Subject to Deductible & 10% Co-Insurance

Out-of-Network: Subject to Deductible & 10% Co-Insurance

$0 after Deductible

 
HOSPITAL &

PHYSICIAN SERVICES

 
In-Network: Subject to Deductible & 20% Co-Insurance

Out-of-Network: Subject to Deductible & 40% Co-Insurance

 
IN NETWORK ONLY: Subject to Deductible & 10% Co-Insurance

$300 per Day, up to 5 Days

In-Network: Subject to Deductible & 10% Co-Insurance

Out-of-Network: Subject to Deductible & 30% Co-Insurance

$0 after Deductible

 
Rx DRUG

CARD

 
$100 Annual Deductible, then:

$15 Generic

50% off Name-Brand Formulary

$100 Annual Deductible, then:

$15 Generic

50% off Name-Brand Formulary

$100 Annual Deductible, then:

$15 Generic

50% off Name-Brand Formulary

 
Subject to Deductible, then:

$15 Generic

50% off Name-Brand Formulary

Subject to Deductible, then:

$15 Generic

50% off Name-Brand Formulary

 
DEPENDENT CHILDREN

 
Covered until 19 or 23 if Full Time Student

 
Covered until 19 or 23 if Full Time Student

 
Covered until 19 or 23 if Full Time Student