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Oxford Freedom Network

450A Oxford Freedom Gold PPO

Oxford Freedom Network

Oxford Freedom Gold PPO — $25/$40 copays, $1,500 deductible, 20% coinsurance, out-of-network coverage, no referrals.

Monthly premiums

Member: $1,789.00/mo
Member & Children: $3,025.00/mo
Member & Spouse: $3,536.00/mo
Member & Family: $4,744.00/mo

Plan details

Deductible (Individual): $1,500
Deductible (Family): $3,000
Out-of-Pocket Max (Individual): $7,250
Out-of-Pocket Max (Family): $14,500
Coinsurance (In-Network): 20%
Primary Care Copay: $25
Specialist Copay: $40
Urgent Care Copay: $75
ER Copay: $500

Benefits

Deductible
$1,500 / $3,000
OON: $4,000 / $8,000
Max Out of Pocket
$7,250 / $14,500
OON: $10,500 / $21,000
Copay
$25 / $40 / $75
PCP / Specialist / Urgent Care
Coinsurance
20% after deductible
OON: 40%
Emergency Room
$500 copay
In & out of network
Rx Coverage
$10 / $40 / $80
Generic / Preferred / Non-Preferred; $150 Rx ded
Pregnancy
Covered
Mental Health
Covered
$40 outpatient; 20% inpatient
Hospital Admission
20% coinsurance
After deductible
Referrals
Not Required
Dependents
To Age 26
Coverage
Nationwide
Oxford Freedom Network + out-of-network
Work Requirement
Work Required

Plan documents

Summary of Benefits and Coverageadmin_upload

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