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Oxford LF Liberty EPOLow PlanOxford LF Liberty PPOMid PlanOxford LF Freedom PPOHigh PlanPlan Name LibE2000i100LX21B LibP1000i100LX21B FrP0MAX2000LX24BIN-NETWORK BENEFITSDeductible(Employee/Family) $2,000 / $4,000 $1,000 / $2,000 $0/$0Coinsurance(Member/Carrier) 100%/0% 100%/0% 100%/0%Maximum Out of PocketCost (MOOP)(Employee/Family)$4,000 / $8,000 $3,500 / $7,000 $0/$0Primary Care Provider(PCP) Copay $25 Deductible Waived $25 Deductible Waived $0 CopayWellness & Preventative Covered at 100% Covered at 100% Covered at 100%Specialist Copay $75 Deductible Waived $75 Deductible Waived $0 CopayInpatient Hospitalization 0% After Deductible $750 copay $750 copayOutpatient Facility 00% After Deductible $750 copay $750 copayEmergency Room $300 then 0% AfterDeductible$300 copay - AfterDeductible $250 copayUrgent Care $50 Deductible Waived $50 Deductible Waived $0 CopayLaboratory 0% After Deductible 0% After Deductible $0 CopayX-Ray 0% After Deductible 0% After Deductible $0 CopayImaging (CT, MRI, PET) 0% After Deductible 0% After Deductible $0 CopayOUT-OF-NETWORK BENEFITSDeductible (Employee /Family)Emergency Only$2,000 / $4,000 $4,000 / $8,000Coinsurance (Member /Carrier) 50% /50% 50% /50%Maximum Out of PocketCost (MOOP)(Employee /Family)$7,000 / $14,000 $8,000 / $16,000PRESCRIPTION Rx BENEFITSGenericPreferred Brand Non-Preferred BrandTier 1: $10 CopayTier 2: $35 CopayTier 3: $75 CopayTier 4: $250 Copay Tier 1: $10 CopayTier 2: $35 CopayTier 3: $75 CopayTier 4: $250 CopayTier 1: $5 CopayTier 2: $30 CopayTier 3: $65 CopayTier 4: $150 CopayRx Deductible N/A N/A N/AHEALTH PLANSRefer to your Summary of BenefitCoverage (SBC) for full policy details,limitations, and exclusions.7