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OXFORD
HEALTH PLANS (NJ), INC. Glenview Hotel |
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| BENEFIT | IN-NETWORK | OUT-OF-NETWORK |
| FINANCIAL | ||
| Deductible: Single Family |
None | $250 |
| None | $500 | |
| Coinsurance | None | 20% |
| Maximum Out-Of-Pocket: Single Family |
Not Applicable | $1,250 (Including Deductible) |
| Not Applicable | $2,500 (Including Deductible) | |
| Maximum Lifetime Benefit Per Member | Unlimited | Unlimited |
| PREVENTIVE CARE | ||
| Physical Examination | No Charge | In Network Benefit Only |
| Routine pediatric care | No Charge | In Network Benefit Only |
| Immunizations | No Charge | In Network Benefit Only |
| Preventive dental for children (Under age 12) | No Charge | No Charge |
| OUTPATIENT CARE | ||
| Physician office visits | $15 copay per visit | Subject to Deductible & Coinsurance |
| Surgery ** | No Charge | Subject to Deductible & Coinsurance ** |
| Laboratory services | At Quest Diagnostic or Other Participating | Subject to Deductible & Coinsurance |
| Laboratory Only; No Charge | ||
| Magnetic Resonance Imaging (MRI) | No Charge | Subject to Deductible & Coinsurance |
| ALLERGY CARE | ||
| Initial visit, and all subsequent referral visits | $15 copay per visit | Subject to Deductible & Coinsurance |
| HOSPITAL CARE | ||
| Physician's and surgeon's services ** | No Charge | Subject to Deductible & Coinsurance ** |
| Semi-private room and board ** | No Charge | Subject to Deductible & Coinsurance ** |
| All drugs and medication | No Charge | Subject to Deductible & Coinsurance |
| EMERGENCY CARE | ||
| (Oxford must be contacted within 48 hours) | ||
| Ambulance service when Medically Necessary | No Charge | No Charge |
| At hospital emergency room | $35 copay; waived if admitted | $35 copay; waived if admitted |
| Emergency Care in Urgi-Center | $15 copay per visit | Subject to Deductible & Coinsurance |
| MATERNITY CARE | ||
| Prenatal and post-natal care ** | No Charge | Subject to Deductible & Coinsurance ** |
| Hospital services for mother and child ** | No Charge | Subject to Deductible & Coinsurance ** |
| MENTAL HEALTH CARE | ||
| 30 days of inpatient care per calendar year ** | No Charge | IN-NETWORK BENEFIT ONLY |
| 20 outpatient visits per calendar year | 50% Copayment | After deductible, 50% Coinsurance |
| ALCOHOLISM SERVICES | ||
| Inpatient care** | No Charge | Subject to Deductible & Coinsurance ** |
| Outpatient care** | $15 copay per visit | Subject to Deductible & Coinsurance ** |
| SUBSTANCE ABUSE | ||
| 7 days of inpatient detox. per calendar year ** | No Charge | IN-NETWORK BENEFIT ONLY |
| 30 days of inpatient rehab. per calendar year ** | No Charge | IN-NETWORK BENEFIT ONLY |
| 60 outpatient rehab. visits per calendar year ** | At approved facilities only; No Charge | Subject to Deductible & Coinsurance ** |
| HOME HEALTH CARE | ||
| 60 home care visits ** | $15 copay per visit | Subject to Deductible & Coinsurance ** |
| Physician house calls | $15 copay per visit | Subject to Deductible & Coinsurance |
| SKILLED NURSING FACILITY | ||
| 30 days per calendar year ** | No Charge | Subject to Deductible & Coinsurance ** |
| CHIROPRACTIC CARE | $500 maximum payment per calendar year | |
| Chiropractic visits | $15 copay per visit | Subject to Deductible & 50% Coinsurance |
| HOSPICE CARE (180 Days) | ||
| Inpatient** | No Charge | Subject to Deductible & Coinsurance ** |
| Outpatient** | No Charge | Subject to Deductible & Coinsurance ** |
| SHORT TERM REHABILITATION | ||
| 60 consecutive inpatient days per condition/lifetime** | No Charge | Subject to Deductible & Coinsurance ** |
| 60 outpatient visits per condition, per lifetime | $15 copay per visit | Subject to Deductible & Coinsurance ** |
| EXERCISE FACILITY | ||
| Subscriber | $100 reimbursement per 6 months | $100 reimbursement per 6 months |
| Spouse | $50 reimbursement per 6 months | $50 reimbursement per 6 months |
| PRESCRIPTION DRUGS | ||
| Per generic prescription**** | $7 copay | Not Covered |
| Per brand name prescription**** | $20 copay | Not Covered |
| OTHER ITEMS | ||
| Durable Equipment | Precertified by Oxford in advance and | Subject to Deductible & Coinsurance ** |
| (when Medically Necessary**) | ordered by an Oxford Participating Physician | |
| Medical Supplies | OUT-OF-NETWORK BENEFIT ONLY | Subject to Deductible & Coinsurance ** |
| (when Medically Necessary**) | ||
| DEPENDENT ELIGIBILITY | ||
| Eligible dependents include the employee's spouse and dependent children until the child reaches age 19, or age 23 if a full time student. | ||
| Benefits discontinue at the end of the semester. | ||
| ** These services require precertification through Oxford. You must call Oxford at 800-444-6222 at least 14 days in advance of treatment to request precertification. | ||
| ****Prescription medications ordered through the Mail Order Drug Program are subject to the retail pharmacy copays. (Generic drugs will be subject to the generic copays and Brand Name Drugs will be subject | ||
| to the brand name copays). The Prescription Drug Benefit is based on a Per Contract Year limit. | ||
| Please note: This Summary of Coverage is for informational purposes only. The applicable Summary of Benefits will be | ||
| issued to eligible, enrolled members. Coverage is subject to the limitations and exclusions contained in your Oxford Certificate of Coverage. | ||