Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage Period: 10/01/2019-09/30/2020

UnitedHealthcare/Oxford1: NY FREEDOM NG 10/10/0/100 ACCESS Coverage for: Employee + Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.welcometouhc.com/oxford. For
general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the
Glossary. You can view the Glossary at http://www.dol.gov/ebsa/healthreform or http://www.cciio.cms.gov/ or call 1-800-444-6222 to request a copy.
Important Questions Answers Why This Matters:

What is the overall Non-Network: $250 Individual / $500 Family See the Common Medical Events chart below for your costs for services this plan
deductible? Per calendar year. covers.

Are there services

See the Common Medical Events chart below for your costs for services this plan
covered before you No.
covers.
meet your deductible?
Are there other
deductibles for No. You don’t have to meet deductibles for specific services.
specific services?
What is the out-of- Network: $2,500 Individual / $5,000 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you
pocket limit for this have other family members in this plan, they have to meet their own out-of-pocket limits
Non-Network: $1,250 Individual / $2,500 Family
plan? until the overall family out-of-pocket limit has been met.
What is not included
Premiums, balance-billing charges, health care
in
this plan doesn’t cover and penalties for failure Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
the out-of-pocket
to obtain preauthorization for services.
limit?
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network. You will pay the most if you use an out-of-network provider, and you might
Will you pay less if
Yes. See www.myuhc.com or call 1-800-444- receive a bill from a provider for the difference between the provider’s charge and what
you use a network
6222 for a list of network providers. your plan pays (balance billing). Be aware, your network provider might use an out-of-
provider?
network provider for some services (such as lab work). Check with your provider before
you get services.

Do you need a referral

No. You can see the specialist you choose without a referral.
to see a specialist?
1 Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc., and Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.

1 of 6  OMB Control Numbers 1545‐2229, 1210‐0147, and 0938‐1146 
Released on April 6, 2016  
 
 What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Services You May Need Network Provider Provider
Medical Event Information
(You will pay the least) (You will pay the
most)
Virtual visits (Telehealth) - $5 copay per visit by a Designated
Primary care visit to treat Virtual Network Provider. If you receive services in addition
$10 copay per visit 20% coinsurance
an injury or illness to office visit, additional copays, deductibles, or
coinsurance may apply e.g. surgery.
If you receive services in addition to office visit, additional
If you visit a health
Specialist visit $10 copay per visit 20% coinsurance copays, deductibles, or coinsurance may apply e.g.
care provider’s office
surgery.
or clinic
You may have to pay for services that aren’t preventive.
Preventive Ask your provider if the services needed are preventive.
care/screening/ No Charge 20% coinsurance Then check what your plan will pay for. Adult non-
immunization network: Certain adult services are covered when using a
non-network provider.
Diagnostic test (x-ray, Preauthorization required non-network for certain
No Charge 20% coinsurance
blood work) services or benefit reduces to the lesser of 50% or $500.
If you have a test
Imaging (CT/PET scans, Preauthorization required non-network for certain
No Charge 20% coinsurance
MRIs) services or benefit reduces to the lesser of 50% or $500.
Provider means pharmacy for purposes of this section.
Retail: $7 copay Retail: Up to a 31 day supply. Mail-Order: Up to a 90 day
Tier 1 Not Covered
Mail-Order: $17.50 copay supply. You may need to obtain certain drugs, including
certain specialty drugs, from a pharmacy designated by
If you need drugs to
us. Certain drugs may have a preauthorization
treat your illness or
Retail: $15 copay requirement or may result in a higher cost. Certain
condition Tier 2 Not Covered
Mail-Order: $37.50 copay preventive medications (including certain contraceptives)
More information about
are covered at No Charge. See the website listed for
prescription drug
information on drugs covered by your plan. Not all drugs
coverage is available at
Retail: $35 copay are covered. You may be required to use a lower-cost
www.myuhc.com Tier 3 Not Covered
Mail-Order: $87.50 copay drug(s) prior to benefits under your policy being available
for certain prescribed drugs.

Tier 4 Not Applicable Not Applicable Tier not applicable for this plan.

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 What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Services You May Need Network Provider Provider
Medical Event Information
(You will pay the least) (You will pay the
most)
Facility fee (e.g.,
Preauthorization required non-network for certain
ambulatory surgery No Charge 20% coinsurance
If you have outpatient services or benefit reduces to the lesser of 50% or $500.
center)
surgery
Preauthorization required non-network for certain
Physician/surgeon fees No Charge 20% coinsurance
services or benefit reduces to the lesser of 50% or $500.
Emergency room care $50 copay per visit $50 copay per visit None
Emergency medical
If you need immediate No Charge No Charge None
transportation
medical attention
If you receive services in addition to urgent care visit,
Urgent care $10 copay per visit 20% coinsurance additional copays, deductibles, or coinsurance may apply
e.g. surgery.
Facility fee (e.g., hospital Preauthorization required non-network for certain
$0 copay per visit 20% coinsurance
If you have a hospital room) services or benefit reduces to the lesser of 50% or $500.
stay Preauthorization required non-network for certain
Physician/surgeon fees No Charge 20% coinsurance
services or benefit reduces to the lesser of 50% or $500.
Network partial hospitalization/intensive outpatient
If you need mental treatment: No Charge. Preauthorization required non-
Outpatient services $10 copay per visit 20% coinsurance
health, behavioral network for certain services or benefit reduces to the
health, or substance lesser of 50% or $500.
abuse services Preauthorization required non-network for certain
Inpatient services No Charge 20% coinsurance
services or benefit reduces to the lesser of 50% or $500.
Cost sharing does not apply for preventive services.
Office visits No Charge 20% coinsurance Depending on the type of service a copayment,
coinsurance or deductible may apply.
Childbirth/delivery Maternity care may include tests and services described
If you are pregnant No charge 20% coinsurance
professional services elsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery facility Inpatient preauthorization may apply.

No Charge 20% coinsurance
services

3 of 6 
 What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Services You May Need Network Provider Provider
Medical Event Information
(You will pay the least) (You will pay the
most)
20% coinsurance,
Preauthorization required non-network for certain
Home health care $10 copay per visit deductible does not
services or benefit reduces to the lesser of 50% or $500.
apply
Limits per calendar year: Physical, speech and
$10 copay per outpatient occupational therapy combined limit 90 visits.
Rehabilitation services 20% coinsurance
visit Preauthorization required non-network for certain
services or benefit reduces to the lesser of 50% or $500.
Limits per calendar year: Physical, speech and
If you need help
$10 copay per outpatient occupational therapy combined limit 90 visits.
recovering or have Habilitation services 20% coinsurance
visit Preauthorization required non-network for certain
other special health
services or benefit reduces to the lesser of 50% or $500.
needs
Limited to 30 days per calendar year. Preauthorization
Skilled nursing care No Charge 20% coinsurance required non-network for certain services or benefit
reduces to the lesser of 50% or $500.
Durable medical Preauthorization required for DME over $500 or there is
No Charge 20% coinsurance
equipment no coverage.
Preauthorization required non-network before admission
Hospice services No Charge 20% coinsurance for an Inpatient Stay in a hospice facility or benefit
reduces to the lesser of 50% or $500.
Children’s eye exam Not Covered Not Covered No coverage for Children’s eye exam.
If your child needs Children’s glasses Not Covered Not Covered No coverage for Children’s glasses.
dental or eye care Children’s dental check-
Not Covered Not Covered No coverage for Children’s dental check-up.
up

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
 Acupuncture  Private duty nursing
 Long-term care
 Children’s glasses  Routine eye care (Adult/Child)
 Non-emergency care when travelling outside -
 Cosmetic surgery  Routine foot care
the U.S.
 Dental care (Adult/Child)  Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
 Chiropractic (Manipulative) care
 Bariatric Surgery  Infertility Treatment
 Hearing Aids
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 Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Department of Health
and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be
available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit
www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact: your human resource department, the Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform or the New York
Department of Financial Services at 1-800-342-3736 or www.dfs.ny.gov/index.htm.

Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-866-633-2446.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-633-2446.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-866-633-2446.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-633-2446.

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

5 of 6 
 About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and
hospital delivery) controlled condition) follow up care)
 The plan’s overall deductible $0  The plan’s overall deductible $0  The plan’s overall deductible $0
 Specialist copay $10  Specialist copay $10  Specialist copay $10
 Hospital (facility) copay $0  Hospital (facility) copay $0  Hospital (facility) copay $0
 Other coinsurance 0%  Other coinsurance 0%  Other coinsurance 0%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including disease Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $30 Copayments $700 Copayments $100
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $30 Limits or exclusions $0
The total Peg would pay is $90 The total Joe would pay is $730 The total Mia would pay is $100

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The plan would be responsible for the other costs of these EXAMPLE covered services.
We do not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin,
you can send a complaint to the Civil Rights Coordinator.
Online: [email protected]
Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake
City, UTAH 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to
you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again.
If you need help with your complaint, please call the toll-free number listed within this Summary of
Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.
Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)
Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH
Building Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large
print. Or, you can ask for an interpreter. To ask for help, please call the number contained within this
Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su
disposición. Llame al número gratuito que aparece en este Resumen de Beneficios y Cobertura
(Summary of Benefits and Coverage, SBC).

(Chinese)
(Summary of Benefits and Coverage, SBC)

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PAUNAWA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng
tulong sa wika. Pakitawagan ang toll-free na numerong nakalista sa Buod na ito ng Mga Benepisyo at
Saklaw (Summary of Benefits and Coverage o SBC).

ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является
русском (Russian). Позвоните по бесплатному номеру телефона, указанному в данном «Обзоре
льгот и покрытия» (Summary of Benefits and Coverage, SBC).
‫ يُرجى االتصال برقم الهاتف المجاني المدرج‬.‫ فإن خدمات المساعدة اللغوية المجانية متاحة لك‬،)Arabic( ‫ إذا كنت تتحدث العربية‬:‫تنبيه‬
.‫) هذا‬Summary of Benefits and Coverage، SBC( ‫بداخل مخلص المزايا والتغطية‬

ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w
nan lang pa w. Tanpri rele nimewo gratis ki nan Rezime avantaj ak pwoteksyon sa a (Summary of
Benefits and Coverage, SBC).

ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés
gratuitement. Veuillez appeler le numéro sans frais figurant dans ce Sommaire des prestations et de la
couverture (Summary of Benefits and Coverage, SBC).

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zadzwonić pod bezpłatny numer podany w niniejszym Zestawieniu świadczeń i refundacji (Summary of
Benefits and Coverage, SBC).

ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito.
Ligue para o número gratuito listado neste Resumo de Benefícios e Cobertura (Summary of Benefits and
Coverage - SBC).

ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza
linguistica gratuiti. Chiamate il numero verde indicato all'interno di questo Sommario dei Benefit e della
Copertura (Summary of Benefits and Coverage, SBC).

ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die in dieser Zusammenfassung der Leistungen und
Kostenübernahmen (Summary of Benefits and Coverage, SBC) angegebene gebührenfreie Rufnummer an.

注意事項：日本語 (Japanese) を話される場合、無料の言語支援サービスをご利用いただけます。

本「保障および給付の概要」(Summary of Benefits and Coverage, SBC) に記載されているフリー
ダイヤルにてお電話ください。

‫ لطفا ً با شماره تلفن رايگان‬.‫ خدمات امداد زبانی به طور رايگان در اختيار شما می باشد‬،‫) است‬israF( ‫ اگر زبان شما فارسی‬:‫توجه‬
.‫) تماس بگيريد‬Summary of Benefits and Coverage، SBC( ‫ذکر شده در اين خالصه مزايا و پوشش‬

ध्यान दें : यदद आप ह द

िं ी (Hindi) बोलते है , आपको भाषा सहायता सेबाएं, नन:शुल्क उपलब्ध हैं। लाभ
और कवरे ज (Summary of Benefits and Coverage, SBC) के इस साराांश के भीतर सूचीबद्ध टोल फ्री नांबर
पर कॉल करें ।

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu
rau tus xov tooj hu dawb teev muaj nyob ntawm Tsab Ntawv Nthuav Qhia Cov Txiaj Ntsim Zoo thiab
Kev Kam Them Nqi (Summary of Benefits and Coverage, SBC) no.

ចំណាប់អារម្មណ៍ៈ បបើសិនអ្នកនិយាយភាសាខ្មមរ (Khmer) បសវាជំនួយភាសាបោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។

សូម្ទូរស័ព្ទបៅបេមឥតបចញថ្លៃ ខ្ែេមានកត់បៅកនុង បសចកដីសបងេបអ្តថប្បបយាជន និងការរា៉ាបង់រង (Summary of Benefits and
Coverage, SBC) បនេះ។
PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan
bayadna, ket sidadaan para kenyam. Maidawat nga awagan ti awan bayad na nu tawagan nga numero
nga nakalista iti uneg na daytoy nga Dagup dagiti Benipisyo ken Pannakasakup (Summary of Benefits
and Coverage, SBC).

DÍÍ BAA'ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti'go, saad bee áka'anída'awo'ígíí, t'áá jíík'eh,
bee ná'ahóót'i'. T'áá shǫǫdí Naaltsoos Bee 'Aa'áhayání dóó Bee 'Ak'é'asti' Bee Baa Hane'í (Summary of
Benefits and Coverage, SBC) biyi' t'áá jíík'ehgo béésh bee hane'í biká'ígíí bee hodíilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah,
ayaad heli kartaa. Fadlan wac lambarka bilaashka ah ee ku yaalla Soo-koobitaanka Dheefaha iyo
Caymiska (Summary of Benefits and Coverage, SBC).