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PLAN 1HSA - FREEDOM NETWORKPLAN 2FREEDOM NETWORKPLAN 3LIBERTY NETWORKPlan Name NY G FRDM NG 2000/100 EPO HSA NY G FRDM NG 50/50/1000/90 EPO NY G LBTY NG 25/50/100 EPO ZDIN-NETWORK BENEFITSDeductible(Employee/Family) $2,000-Single / $4,000-Family $1,000-Single / $2,000-Family $0 -No DeductibleCoinsurance(Member/Carrier) 0% member / 100% Oxford 10% member / 90% Oxford 0% member / 100% OxfordMaximum Out of Pocket Cost(MOOP)(Employee/Family) $7,050 / $14,100 (Including Ded) $6,700 / $13,400 (Including Ded) $7,000 / $14,000Primary Care Provider (PCP) Copay No Charge After Deductible $50 copay Deductible Waived $25 CopayWellness & Preventative Covered at 100% Covered at 100% Covered at 100%Specialist Copay No Charge After Deductible $50 copay Deductible Waived $50 CopayInpatient Hospitalization No Charge After Deductible $250 per Day After Deductible $500 per AdmitOutpatient Facility No Charge After Deductible Free Standing Lab: $150 After DeductibleOutpatient Hospital: 10% After Deductible $250 CopayEmergency Room 50% After Deductible $500 copay (Waived if Admitted) $750 (Waived if Admitted)Urgent Care No Charge After Deductible $75 copay Deductible Waived $75 CopayLaboratory No Charge After Deductible Free Standing Lab: 50% After DeductibleOutpatient Hospital: 50% After Deductible No ChargeX-Ray No Charge After Deductible Free Standing Lab: $80 After DeductibleOutpatient Hospital: $80 After Deductible $50 CopayImaging (CT, MRI, PET) No Charge After Deductible Free Standing Lab: $150 After DeductibleOutpatient Hospital: $150 After Deductible $150 CopayOUT-OF-NETWORK BENEFITSMaximum Out of Pocket Cost(MOOP)(Employee / Family) EMERGENCY ONLY EMERGENCY ONLY EMERGENCY ONLYPRESCRIPTION Rx BENEFITSGeneric Preferred BrandNon-Preferred Brand $10/$40/$80 $10/$40/$80/$150 $10/$50/$90/$200Rx Deductible Integrated with Medical Deductible applies for Tier 2 & 3 Ded T2-3OXFORD HEALTH PLANSRefer to your Summary of BenefitCoverage (SBC) for full policy details,limitations, and exclusions.The plans being offered all utilize a national network.7