F Gold PPO 25-40 Non-Gated OHI CNT by Oxford
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Plan Information
- Plan Name
- F Gold PPO 25-40 Non-Gated OHI CNT
- Insurance Company
- Oxford
In Network Benefits
- Office Co-pay
- $25
- Specialist Co-pay
- $40
- Hospital Co-pay
- 20% after deductible
- Emergency Room
- $300
- Referrals Needed
- No
- Rx: Generic/Brand/High Brand
- $10(deductible waived)/$35/$75 after $100 deductible
- In-Network Co-Insurance
- 20%
- Max Out of Pocket (single/family)
- $4,000/$8,000
Out Of Network Benefits
- Deductible (single/family)
- $3,000/$6,000
- Co-Insurance
- 40%
- Out of Pocket Max (single/family)
- $7,500/$15,000
Other Benefits
- Vision/Dental
- Pediatric Vision and Dental
- Renewal Date
- Calendar/Annual
- HSA Eligible
- No
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