unitedhealthcareloxford: oxf-lib epo 8b-snj epo liberty ......unitedhealthcareloxford: oxf-lib epo...

UnitedHealthcarelOxford: OXF-LIB EPO 8B-SNJ EPO Liberty

Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Coverage Period: 06/01/2013 - 05/31/2014 Coverage for: Employee + Family I Plan Type: EPO

•

44. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at

Important www.oxh• .com or b callino the Member Service number listed on the back of our ID card.

Questions Answers Why This Matters:

What is the overall deductible?

Network: $2,500 Individual / $5,000 Family Does not apply to copays, pharmacy drugs, and services listed below as "No Charge'. Per Calendar Year.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the Common Medical Events chart for how much you pay for covered services after you meet the deductible.

Are there specific

other deductibles for Yes, $50 Individual for Pharmacy expenses. You must pay all of the costs for these services up to the

specific deductible amount before this plan begins to pay for services? these services.

Is there my expenses?

an out-of-pocket limit on Network: $7,500 Individual / $15,000 Family Other limits apply - see chart that starts on page 2.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is pocket

not included in the out-of— Premium, balance-billed charges, health care this plan doesn't cover, and penalties for failure to obtain pre- authorization for services.

Even though you pay these expenses, they don't count toward the out—of—pocket limit. limit?

Is there what the

an overall annual limit on No, this policy has no overall annual limit on the amount it will pay each year.

The Common Medical Events chart describes any limit on what the plan will pay for specific covered services, such as office visits.

plan pays?

Does this providers?

r- Do I need s • ecialist?

plan use a network of

Yes. See www.oxhp.com or Call 1-800-444-6222 for a list of participating doctors and hospitals.

If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use a non-network provider for some services. Plans use the term network, preferred, or participating for • roviders in their network. See the Common Medical Events chart for how this plan pays different kinds of • roviders.

a referral to see a No. You don't need a referral to see a specialist. You can see the s • ecialist you choose without permission from this plan.

Are there services this plan doesn't cover?

Yes. Some of the services this plan doesn't cover are listed under Services Your Plan Does NOT Cover. See your policy or plan document for additional information about excluded services.

Questions: Call 1-800-444-6222 or visit us at www.oxhp.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov , or call the telephone numbers above to request a copy. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan.

1 of 8

Primary care visit to treat an injury or illness

Specialist visit

If you visit a health care provider's office or clinic Other practitioner office visit

$50 copay per visit

$30 copay per visit for Manipulative (Chiropractic) Services No Charge

No Charge

50% co-ins

Preventive care/screening/immunizations

If you have a test

Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRls)

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

$75 copay per visit Not Covered

UnitedHealthcare/Oxford: OXF-LIB EPO 8B-SNJ EPO Liberty

• Co-payments (copays) are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Co-insurance (co-ins) is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For

example, if the plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If a Non-Network Provider charges more than the allowed amount, you may have to pay the difference. For example, if a Non-Network Provider hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use_participating providers by charging you lower deductible, co-payments and co-insurance amounts.

Your cost if you use a Common Medical Event Services you may need

Network Provider

Non-Network I Limitations & Exceptions Provider

•

If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. Pre-Authorization required or benefit reduces to 50% of allowed.

Includes preventive health services specified in the health care reform law. Radiology Covered at Deductible then 50% co-ins. Pre-Authorization required or benefit reduces to 50% of allowed.


2 of 8

Tier 4 - Additional High-Cost Options Facility fee (e.g., ambulatory surgery center)

Physician/surgeon fees Emergency room services

Emergency medical transportation Urgent care

Not Applicable

50% co-ins

50% co-ins $100 copay then 50% co-ins per visit 50% co-ins $75 copay per visit

Not Applicable

- ----- --- Not Covered

Not Covered $100 copay then 50% co-ins per visit Not Covered Not Covered

If you have outpatient surgery

If you need immediate medical attention

If you have a hospital Facility fee (e.g., hospital room) stay

50% co-ins Not Covered

Physician/ surgeon fee

50% co-ins Not Covered


Common Medical Event Services you may need Your cost if

Network Provider ru use a

I Non-Network Provider

Limitations & Exceptions

Provider means pharmacy for purposes of this section. Retail: Up to a 31 day supply. Mail-Order: Up to a 90 day supply. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us. Certain drugs may have a pre- authorization requirement or may result in a higher cost. Tier 1 Contraceptives covered at No Charge. Pharmacy Deductible does not apply to Tier 1. Oral chemotherapeutic agents are covered at No Charge.

Pre-Authorization required or benefit reduces to 50% of allowed. None None

None If you receive services in addition to urgent care, additional copays, deductibles or co-ins may apply. Pre-Authorization required or benefit reduces to 50% of allowed. None

If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.oxhp.com .

Tier 1 - Your Lowest-Cost Option

Tier 2 - Your Mid-Range Cost Option

Retail: $10 copay Mail-Order: $20 copay


Not Covered

Not Covered

Not Covered

Tier 3 - Your Highest-Cost Option Retail: $50 copay Mail-Order: $100 copay


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If you have mental health, behavioral health, or substance abuse needs

If you become pregnant

If you have a recovery or other special health need

Mental/Behavioral health outpatient services

Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care

Delivery and all inpatient services Home health care

Rehabilitation services

Habilitation services Skilled nursing care

Durable medical equip_Ment Hospice service

$75 copay per visit

50% co-ins

$75 copay per visit

50% co-ins

$50 copay per initial visit

50% co-ins

$75 copay per visit

$50 copay per outpatient visit

Not Covered 50% co-ins

50% co-ins 50% co-ins

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

[Not Covered

Not Covered Not Covered

Not Covered Not Covered



Network Provider Non-Network


Provider Pre-Authorization required or benefit reduces to 50% of allowed.

Pre-Authorization required or benefit reduces to 50% of allowed. Pre-Authorization required or benefit reduces to 50% of allowed. Pre-Authorization required or benefit reduces to 50% of allowed. Additional copays, deductibles or co-ins may apply. Routine pre-natal care is covered at No Charge. Pre-Authorization required or benefit reduces to 50% of allowed. Limited to 60 visits per Calendar Year. Pre-Authorization required or benefit reduces to 50% of allowed. Limited to 90 visits per Calendar Year. Pre-Authorization required or benefit reduces to 50% of allowed. No coverage for habilitation services. Pre-Authorization required or benefit reduces to 50% of allowed. Pre-Authorization required for items over $500. Limited to 180 days (combined inpatient, outpatient and home hospice). Inpatient Pre-Authorization required or benefit reduces to 50% of allowed.


4 of 8


Your cost if you use a Common Medical Event

Services you may need



Provider

Eye exam

Not Covered

Not Covered No Charge

Not Covered

No coverage for Eye exam.

If your child needs dental or eye care

Glasses Dental check-up

No coverage for Glasses. For children through age 11. Limited to 1 visit per Calendar Year.


Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn't a complete list. Check yourpolicy for othersj • Acupuncture • Cosmetic surgery • Dental check-up (adult) • Glasses

• Habilitation Services • Long-term care • Non-emergency care when traveling outside

the U.S. • Private-duty nursing

• Routine eye care (adult/child) • Routine foot care • Weight loss programs

Other Covered Services (This isn't a complete list. Check your policy for other covered services and your cost for these services.) • Bariatric surgery may be covered with • Hearing aids may be covered with • Infertility treatment may be covered with limitations

limitations limitations

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan, Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-866-747-1019. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or visit www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or visit www.cciio.cms.gov .


5 of 8


Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your human resource department or the Employee Benefits Security Administration at 1-866-444-3272 or visit www.dol.gov/ebsa/healthreform or New Jersey Department of Banking and Insurance at 1-800-446-7467 or visit http://www.state.nj.us/dobi/index.html,

Additionally, a consumer assistance program may help you file your appeal. Contact New Jersey Department of Banking and Insurance at 1-800-446-7467 or 1-888-393-1062 for appeals or visit http://www.state.nj.us/dobi/consumer.htm . A list of states with Consumer Assistance Programs is available at www.dol.gov/ebsa/healthreform and http:///ciio.cms.gov/prgrams/consumer/capgrantsfindex.html.

Para obtener asistencia en espanol, Ilame al numero de telefono en su tarjeta de identificaciOn Rtt, Lti/Ifii] ,

Dine k'ehji shich'i' hadoodzih ninizingo, bee neehozin biniiye nanitinigii number bikaa'igii bich'i' hodiilnih Para sa tulong sa Tagalog, tawagan ang numero sa iyong ID card.

— To see examp es of how this plan might cover costs for a sample medical situation, see the next pag


6 of 8


About these Coverage Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

This is not a cost estimator.

Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost also will be different.

See the next page for important information about these examples

Having a baby (normal delivery)

• Amount owed to providers: $7,540 • Plan Pays $3,840 • Patient Pays $3,700

Sample care costs:

Hospital charges (mother)

$2,700

Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200

Radiology $200 Vaccines, other preventive $40

Total $7,540

Patient pays:

Deductibles $2,500

Co-pays $0

Co-insurance $1,000

Limits or exclusions $200

Total $3,700

Managing type 2 diabetes (routine maintenance of a well-controlled

condition) • Amount owed to providers: $5,400 • Plan Pays $3,520 • Patient Pays $1,880

Sample care costs:

Prescriptions $2,900

Medical Equipment and Supplies

$1,300

Office visits and procedures

$700

Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays:

Deductibles $1,100

Co-pays $700

Co-insurance $0


Total $1,880


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Questions and answers about the Coverage Examples: What does a Coverage Example show?

What are some of the assumptions behind the Coverage Examples? • Costs don't include premiums. • Sample care costs are based on national

averages supplied to the U.S. Department of Health and Human Services (HHS), and aren't specific to a particular geographic area or health plan.

• Patient's condition was not an excluded or preexisting condition.

• All services and treatments started and ended in the same policy period.

• There are no other medical expenses for any member covered under this plan.

• Out-of-pocket expenses are based only on treating the condition in the examples.

• The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples. The care you would receive for these conditions could be different, based on your doctors advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summaries

of Coverage for other plans, you'll find the

same coverage examples. When you

compare plans, check the "You Pay" box

for each example. The smaller that

number, the more coverage the plan

provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the

premium you pay. Generally, the lower your premium, the more you'll pay in

out-of-pocket costs, such as

copayments, deductibles, and

coinsurance. You also should consider

contributions to accounts such as health

savings accounts (HSAs), flexible

spending arrangements (FSAs) or health

reimbursement accounts (HRAs) that

help you pay out-of-pocket expenses.


8 of 8



Coverage Period: 06/01/2013 - 05/31/2014 Coverage for: Employee + Family I Plan Type: EPO

AL This is only a summary. If you www.oxho.com or b callin• the

Important Questions


want more detail about your coverage and costs, you can Member Service number listed on the back of our ID card.

Answers Network: $1,500 Individual / $3,000 Family Does not apply to copays, pharmacy drugs, and services listed below as "No Charge'. Per Calendar Year.

get the complete terms in the policy or plan document at

Why This Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the Common Medical Events chart for how much you pay for covered services after you meet the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for

Are there other deductibles for Yes, $50 Individual for Pharmacy expenses.

specific services? these services.

Is there an out-of-pocket limit on Network: $4,000 Individual / $8,000 Family Other limits apply - see chart that starts on page 2.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

my expenses?

What is not included in the out-of— Premium, balance-billed charges, health care this plan doesn't cover, and penalties for failure to obtain pre- authorization for services.

Even though you pay these expenses, they don't count toward the out—of—pocket limit.

pocket limit?

Is there an overall annual limit on No, this policy has no overall annual limit on the amount it will pay each year.


what the plan pays?

Does this plan use a network of


If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use a non-network provider for some services. Plans use the term network, 'referred, or participating for • roviders in their network. See

providers?

the Common Medical Events chart for how this plan pays different kinds of •roviders.

Do I need a referral to see a s • ecialist?

No. You don't need a referral to see a specialist. You can see the siecialist you choose without permission from this plan.




1 of 8

Primary care visit to treat an injury or illness

Specialist visit

If you visit a health care provider's office or clinic Other practitioner office visit



$30 copay per visit Not Covered for Manipulative (Chiropractic) Services No Charge

No Charge

30% co-ins

Preventive care/screening/immunizations

If you have a test

Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRIs)

Not Covered

Not Covered

I Not Covered


• Co-payments (copays) are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Co-insurance (co-ins) is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For


• The amount the plan pays for covered services is based on the allowe

-

d amount. If a Non-Network Provider charges more than the allowed amount, you may have to pay the difference. For example, if a Non-Network Provider hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• _This plan may encourage you to use participating_providers by chargingyou lower deductible, co-paymentsand co-insurance amounts.

Common Medical Event Services you may need Your cost if you use a

Network Provider Non-Network 1 Limitations & Exceptions Provider

If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. If you receive services in addition to office visit, additional copays, deductibles, or co-ins mayapply. If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. Pre-Authorization required or benefit reduces to 50% of allowed.

Includes preventive health services specified in the health care reform law. Radiology Covered at Deductible then 30% co-ins. Pre-Authorization required or benefit reduces to 50% of allowed.


2 of 8

UnitedHealthcarelOxford: OXF -LIB EPO 7B -SNJ EPO Liberty


Network Provider I Non-Network Provider





If you have a hospital stay



Tier 3 - Your Highest-Cost Option

Tier 4 - Additional High-Cost Options Facility fee (e.g., ambulatory surgery center)

Physician/surgeon fees

Emergency room services

Emergency medical transportation Urgent care

Facility fee (e.g., hospital room)

Physician/ surgeon fee




Not Applicable

30% co-ins

30% co-ins $100 copay then 30% co-ins per visit 30% co-ins $40 copay per visit

30% co-ins

30% co-ins

Not Covered

Not Covered

Not Covered

Not Applicable

Not Covered

Not Covered $100 copay then 30% co-ins per visit Not Covered Not Covered

Not Covered

Not Covered

Provider means pharmacy for purposes of this section. Retail: Up to a 31 day supply. Mail-Order: Up to a 90 day supply. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us. Certain drugs may have a pre-authorization requirement or may result in a higher cost. Tier 1 Contraceptives covered at No Charge. Pharmacy Deductible does not apply to Tier 1. Oral chemotherapeutic agents are covered at No Charge.

Pre-Authorization required or benefit reduces to 50% of allowed. None

None

None If you receive services in addition to urgent care, additional copays, deductibles or co-ins may apply. Pre-Authorization required or benefit reduces to 50% of allowed. None


3 of 8



30% co-ins

$40 copay per visit


If you have a recovery or other special health Habilitation services need Skilled nursing care

Durable medical equipment Hospice service

$40 copay per outpatient visit


30% co-ins 30% co-ins


Your cost if ou use a Common Medical Event Services you may need

Network Provider

Non-Network

Limitations & Exceptions Provider

$40 copay per visit

30% co-ins

$40 copay per visit

30% co-ins


Not Covered

Pre-Authorization required or benefit reduces to 50% of allowed.

Not Covered Pre-Authorization required or benefit reduces to 50% of allowed.



Not Covered

Additional copays, deductibles or co-ins may apply. Routine pre-natal care is covered at No Charge.


Not Covered Limited to 60 visits per Calendar Year. Pre-Authorization required or benefit reduces to 50% of allowed.

Not Covered Limited to 90 visits perCalendar Year. Pre-Authorization required or benefit reduces to 50% of allowed.

Not Covered

No coverage for habilitation services. Not Covered

Pre-Authorization required or benefit reduces to 50% of allowed.

Not Covered

Pre-Authorization required for items over $500. Not Covered

Limited to 180 days (combined inpatient, outpatient and home hospice). Inpatient Pre-Authorization required or benefit reduces to 50% of allowed.





4 of 8

United HealthcarelOxford: OXF-LIB EPO 7B-SNJ EPO Liberty


Network Provider

Non-Network


Eye exam

Not Covered

Not Covered








Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy for others.) • Acupuncture • Habilitation Services • Routine eye care (adult/child)

• Cosmetic surgery • Long-term care • Routine foot care

• Dental check-up (adult) • Non-emergency care when traveling outside • Weight loss programs

• Glasses the U.S. • Private-duty nursing

Other Covered Services (This isn't a complete list. Check yourpolicy for other covered services and your cost for these services.) • Bariatric surgery may be covered with • Hearing aids may be covered with • Infertility treatment may be covered with limitations


Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you

pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-866-747-1019. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or visit www.dol.gov/ebsa, or the U.S. Department of Health and

Human Services at 1-877-267-2323 x61565 or visit www.cciio.cms.gov .

Questions: Call 1-800-444-6222 or visit us at www.oxhp.com . If you aren't dear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at

www.dol.goviebsaihealthreform or www.cciio.cms.gov , or call the telephone numbers above to request a copy. This is only a summary. It in no way modifies your benefits as described

in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan. 5 of 8

UnitedHeaithcarelOxford: OXF-LIB EPO 7B-SNJ EPO Liberty


If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your human resource department or the Employee Benefits Security Administration at 1-866-444-3272 or visit www.dol.gov/ebsa/healthreform or New Jersey Department of Banking and Insurance at 1-800-446-7467 or visit http:/lwww.state,nj.us/dobi/index.html.

Additionally, a consumer assistance program may help you file your appeal. Contact New Jersey Department of Banking and Insurance at 1-800-446-7467 or 1-888-393-1062 for appeals or visit http://www.state.nj.us/dobi/consumer.htm . A list of states with Consumer Assistance Programs is available at www.dol.gov/ebsa/healthreform and http:///ciio.cms.gov/prgrams/consumer/capgrants/index.html.

Para obtener asistencia en espatiol, (lame al numero de telefono en su tarjeta de identificacion

Dine k'ehji shich'i' hadoodzih ninizingo, bee neehozin biniiye nanitinigii number bikaa'igii bich'i' hodiilnih Para sa tulong sa Tagalog, tawagan ang numero sa iyong ID card.

To see examples of how this plan might cover costs for a sample medical situation, see the next pag

Questions: Call 1-800-444-6222 or visit us at www.oxhp.com . If you aren't dear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov , or call the telephone numbers above to request a copy. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan.

6 of 8




This is not a AM cost estimator.





Sample care costs:


$2,700


Radiology $200 Vaccines, other preventive

$40

Total $7,540

Patient pays:

Deductibles $1,500

Co-pays $0

Co-insurance $900


Total $2,600


condition)


Sample care costs:



$1,300


$700


Deductibles $1,100

Co-pays $700

Co-insurance $0


Total $1,880

Questions: Call 1-800-444-6222 or visit us at www.oxhp.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at

www.dol.gov/ebsa/healthreform or www.cciio.cms.gov , or call the telephone numbers above to request a copy. This is only a summary. It in no way modifies your benefits as described



Questions and answers about the Coverage Examples:

What does a Coverage Example show? What are some of the assumptions behind the Coverage Examples? • Costs don't include premiums. • Sample care costs are based on national


• Patients condition was not an excluded or preexisting condition.






Does the Coverage Example predict my own care needs? A No. Treatments shown are just examples. The care you would receive for these conditions could be different, based on your doctors advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses? X No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.


V Yes. When you look at the Summaries






provides.


Yes. An important cost is the premium you pay. Generally, the lower

your premium, the more you'll pay in


copayments, deductibles, and







Questions: Call 1-800-444-6222 or visit us at www.oxhp.com . If you aren't dear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov, or call the telephone numbers above to request a copy. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan.

8 of 8

UnitedHealthcarelOxford: OXF-FRE Access PPO3B-SNJ Access Freedom


Coverage Period: 06/01/2013 - 05/31/2014 Coverage for: Employee + Family I Plan Type: PPO

411. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at

Important www.oxh • .com or b callins the Member Service number listed on the back of our ID card.

Questions Answers Why This Matters:


Non-Network: $1,000 Individual / $2,500 Family Does not apply to copays, pharmacy drugs, and services listed below as "No Charge". Per Calendar Year.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the Common Medical Events chart for how much you pay for covered services after you meet the deductible.

Are there specific

other deductibles for Yes, $50 Individual for Pharmacy expenses You must pay all of the costs for these services up to the

specific deductible amount before this plan begins to pay for services? these services.

Is there my expenses?

an out-of-pocket limit on Non-Network: $4,000 Individual / $10,000 Family Other limits apply - see chart that starts on page 2.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out—of—pocket limit. What is

pocket not included in the out-of— Premium, balance-billed charges, health care this plan

doesn't cover, and penalties for failure to obtain pre- authorization for services.

limit?

Is there what the

an overall annual limit on No, this policy has no overall annual limit on the amount it will pay each year.


plan pays?

Does this providers?

plan use a network of


If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use a non-network provider for some services. Plans use the term network, preferred, or participating for • roviders in their network. See the Common Medical Events chart for how this plan pays different kinds of • roviders.

Do I need a referral to see a s • ecialist?

No. You don't need a referral to see a specialist. You can see the s•ecialist you choose without permission from this plan.



Questions: Call 1-800-444-6222 or visit us at www.oxhp.com . If you aren't dear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.dol.goviebsa/healthreform or www.ccilo.cms.gov , or call the telephone numbers above to request a copy. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan.

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Primary care visit to treat an injury or

$30 copay per visit

30% co-ins

illness

Specialist visit

$50 copay per visit

30% co-ins

If you visit a health care provider's office or clinic

Other practitioner office visit $30 copay per visit for Manipulative (Chiropractic) Services

50% co-ins per visit for Manipulative (Chiropractic) Services

Preventive care/screening/immunizations No Charge 30% co-ins

If you have a test Diagnostic test (x-ray, blood work)

No Charge 30% co-ins Imaging (CT/PET scans, MRIs)

No Charge 130% co-ins


• Co-payments (copays) are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service._ • Co-insurance (co-ins) is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For


• The amount the plan pays for covered services is based on the allowed amount. If a Non-Network-Provider charges more than the allowed amount, you may have to pay the difference. For example, if a Non-Network Provider hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use_participating providers by charging you lower deductible co-payments and co-insurance amounts.


Network Provider 1 Non-Network I Limitations & Exceptions Provider

If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply._ If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. Non-Network coverage is liniite- - d-6$500 per Member per Calendar Year. Pre-Authorization required Non-Network or benefit reduces to 50% of allowed. If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. Deductible does not apply for Non-

; Network Pediatric Care. Includes preventive health services specified in the health care reform law. None Pre-Authorization required Non-Network or benefit reduces to 50% of allowed._


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UnitedHealthcare/Oxford: OXF-FRE Access PPO3B-SNJ Access Freedom



Network Provider

Non-Network


Provider means pharmacy for purposes of this section. Retail: Up to a 31 day supply. Mail-Order: Up to a 90 day supply. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us. Certain drugs may have a pre-authorization requirement or may result in a higher cost. Tier 1 Contraceptives covered at No Charge. Pharmacy Deductible does not apply to Tier 1. Oral chemotherapeutic agents are covered at No Charge.




Tier 3 - Your Highest-Cost Option




Not Covered

Not Covered

Not Covered



If you have a hospital stay

Tier 4 - Additional High-Cost Options

Not Applicable Not Applicable

Facility fee (e.g., ambulatory surgery center)

$250 copay per visit 30% co-ins Pre-Authorization required Non-Network or benefit reduces to 50% of allowed.

Physician/surgeon fees No Champ 30% co-ins None Emergency room services $100 copay_per visit $100 copay per visit None Emergency_ medical No Charge No Charge None Urgent care $50 copay per visit 30% co-ins If you receive services in addition to urgent

care, additional copays, deductibles or co-ins may apply.

Facility fee (e.g., hospital room) $500 copay per admission 30% co-ins Pre-Authorization required Non -Network or benefit reduces to 50% of allowed.

Physician/ surgeon fee No Charge 30% co-ins None


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$500 copay per admission


30% co-ins

30% co- ins

$500 copay per admission 30% co-ins

No Charge 30% co-ins

$50 copay per outpatient visit 30% co-ins

or other special health Habilitation services need Skilled nursing care

Not Covered $500 copay per admission


If you have a recovery


Your cost if you use a Network Provider Non-Network

Provider

Common Medical Event Services you may need Limitations & Exceptions

30% co-ins

Pre-Authorization required Non-Network or benefit reduces to 50% of allowed.

30% co-ins Pre-Authorization required Non-Network or benefit reduces to 50% of allowed.

30% co-ins Pre-Authorization required Non-Network or benefit reduces to 50% of allowed. Pre-Authorization required Non-Network or benefit reduces to 50% of allowed. Additional copays, deductibles or co-ins may apply. Routine pre-natal care is covered at No Charge. Pre-Authorization required Non-Network or benefit reduces to 50% of allowed. Limited to 60 visits per Calendar Year. Pre-Authorization required Non-Network or benefit reduces to 50% of allowed. Limited to 90 visits per condition, per lifetime. Pre-Authorization required Non -Network or benefit reduces to 50% of allowed. No coverage for habilitition services. Limited to 30 days per Calendar Year. Pre- Authorization required Non-Network or benefit reduces to 50% of allowed.

30% co-ins Pre-Authorization required for items over $500. 30% co-ins Limited to 180 days (combined inpatient,

outpatient and home hospice). Inpatient Pre-Authorization required Non-Network or benefit reduces to 50% of allowed.

$50 copay per visit

$500 copay per admission

$50 copay per visit

Durable medical equipment No Charge Hospice service $500 copay per admission


www.dol.gov/ebsa/healthreform or www.cciio.cms.gov , or call the telephone numbers above to request a copy. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan.

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United Healthcare/Oxford: OXF-FRE Access PPO3B-SNJ Access Freedom





Provider


Eye exam


' Not Covered


Not Covered





Services Your Plan Does NOT Cover (This isn't a complete list. Checkyour_policy for others.)_ • Acupuncture • Cosmetic surgery • Dental check-up (adult) • Glasses

• Habilitation Services • Long-term care • Non-emergency care when traveling outside

the U.S. • Private-duty nursing

• Routine eye care (adultkhild) • Routine foot care • Weight loss programs

Other Covered Services (This isn't a complete list. Check your policy for other covered services and your cost for these services.) • Bariatric surgery may be covered with • Hearing aids may be covered with • Infertility treatment may be covered with limitations


Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-866-747-1019. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or visit www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or visit www.cciio.cms.gov .

Questions: Call 1-800-444-6222 or visit us at www.oxhp.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.dol.goviebsaihealthreform or www.cciio.cms.gov , or call the telephone numbers above to request a copy. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan.

5 of 8



If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your human resource department or the Employee Benefits Security Administration at 1-866-444-3272 or visit www.dol.gov/ebsa/healthreform or New Jersey Department of Banking and Insurance at 1-800-446-7467 or visit http://www.state.nj.us/dobi/index.html.

Additionally, a consumer assistance program may help you file your appeal. Contact New Jersey Department of Banking and Insurance at 1-800-446-7467 or 1-888-393-1062 for appeals or visit http://www.state.nj.us/dobi/consumer.htm . A list of states with Consumer Assistance Programs is available at www.dol.gov/ebsa/healthreform and htto:///ciio.cms.gov/prgrams/consumer/capgrants/index.html.

Para obtener asistencia en espariol, !lame al numero de telefono en su tarjeta de identificacion

gNI=1:1 Z6141],ilit#11- 2. -LE.Eg -stWo Dine k'ehji shich'i' hadoodzih ninizingo, bee neehozin biniiye nanitinigii number bikaa'igii bich'i' hodiilnih Para sa tulong sa Tagalog, tawagan ang numero sa iyong ID card.

To see examples of now this plan might cover costs for a sample medical situation, see the next page

Questions: Call 1-800-444-6222 or visit us at www.oxhp.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov, or call the telephone numbers above to request a copy. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan.

6 of 8




This is not a AllEk cost estimator.




• Amount owed to providers: $7,540 • Plan Pays $6,840 • Patient Pays $700

Sample care costs:


$2 700


Radiology $200 Vaccines, other preventive

$40

Total $7,540

Patient pays:

Deductibles $0

Co-pays $500

Co-insurance $0


Total $700


condition) • Amount owed to providers: $5,400 • Plan Pays $4,020 • Patient Pays $1,380

Sample care costs:



$1,300


$700


Deductibles $100

Co-pays $1,200

Co-insurance $0


Total $1,380


www.dol.gov/ebsa/healthreform or www.cciio.cms.gov , or call the telephone numbers above to request a copy. This is only a summary. It in no way modifies your benefits as described



Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples? • Costs don't include premiums. • Sample care costs are based on national


• Patient's condition was not an excluded or preexisting condition.





What does a Coverage Example show?


Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples. The care you would receive for these conditions could be different, based on your doctor's advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.


✓ Yes. When you look at the Summaries






provides.


Yes. An important cost is the

premium you pay. Generally, the lower

your premium, the more you'll pay in


copavments, deductibles, and








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