_Oposoa

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Ā Benefit Features	MEHIP POS ā€“ In-Network *(Services Provided by a Network Provider)*	MEHIP POS ā€“ Out-of-Network (Services Provided by any Provider)
*Outpatient Physician Visits*	$10 copay	80% after deductible
well-child and immunizations. Preventive dental (under age 12)	$0 copay Age-based schedule	80% after deductible
Diagnostic X-ray and Lab (MRI)	100% at participating laboratories	80% after deductible
Chiropractic/Naturopathic Therapy	$10 copay (treatment plan required for chiro/30 visits per calendar year)	80% after deductible
Allergy Services	$10 copay	80% after deductible
Durable Medical Equipment Ā	Pre certified by Oxford in advance and ordered by an Oxford participating provider	80% after deductible (prior authorization required)
*Prescription Drugs* *Oxford* *: Mac C*	$7 generic/$15 formulary/ $35 non-formulary, 2X mail order copay, UnlimitedĀ maximum, Includes contraceptive drugs	Not covered
Emergency Care	$50 (subject to guidelines, waived if admitted-notification required)	$50 subject to deductible (subject to guidelines, waived if admitted)
Urgent Care	$10 copay (subject to guidelines)	80% after deductible
Ambulance	100% (if emergency)	100% (if emergency)
Pre-admission Testing	100%	80% after deductible
Pre-Admission Certification/Concurrent Review	Through network physician	80% after deductible
*Inpatient* *Hospital*	$250 per admission copay	80% after deductible (pre-certification required)
Inpatient Physician	100% (pre-certification required)	80% after deductible (pre-certification required)
Outpatient Surgical Facility	$0 copayĀ (pre-certification required)	80% after deductible (pre-certification required)
Mental Health	Inpatient ā€“ $250 per admission copay (pre-certification required) Outpatient - $10 copay	80% after deductible (pre-certification required) Ā
Substance Abuse	(pre-certification required)	Ā (pre-certification required)
Ā Ā Ā Ā Inpatient	$250 per admission copay	80% after deductible
Ā Ā Ā Ā Outpatient	No charge	80% Ā after deductible
Ā Ā Ā Ā Family Rehabilitation Ā Ā Ā Ā 20 visits per calendar year	No charge.	Ā 80%Ā after deductible
Skilled Nursing Facility 30 days per calendar year	$250 copay per admittance (pre-certification required)	80% after deductible (pre-certification required)
Home Health Care 80 visits per calendar year	$10 copay (pre-certification required)	80% after deductible (pre-certification required)
Hospice 210 days per lifetime	$250 copayĀ per admittance (pre-certification required)	80% after deductible (pre-certification required)
Dependent Child Rider	19/23 if full time student	Ā
*Deductibles*	Ā	Ā
Ā Ā Ā Ā Individual	None	$250
Ā Ā Ā Ā Family	None	$625
*Coinsurance Limit*	Ā	Ā
Ā Ā Ā Ā Individual	None	$1,000
Ā Ā Ā Ā Family	None	$2,500
*Out-of-Pocket Maximums*	Ā	Ā
Ā Ā Ā Ā Individual	None	$1,250 (Includes Deductible)
Ā Ā Ā Ā Family	None	$3,125 (Includes Deductible)
Coinsurance	None	80/20% of allowable charges
Lifetime Maximum	None	None
This sample summary of coverage is provided for informational purposes only. The applicable summary of benefits will be issued to eligible, enrolled members as part of the certificate.

MEHIP/Oxford Commercial Small Group Plan Point of Service Option-A

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