Oxford Health Plans - New York: Bronx, Kings, New …...York, Queens, and Richmond Counties in New York. You must live in one of these places to join the plan. If you are in prison,

New York: Bronx, Kings, New York, Queens and Richmond Counties

January 1, 2006 - December 31, 2006

Summary of Benefits

You’ve earned the right to live life on your own terms.

And that includes the right to affordable healthcare.

OXFORD MEDICARE ADVANTAGE® MOSAICSM • $0 monthly plan premium*

• No referrals required

• $0 primary care physician visit copayment

• $5 specialist visit copayment

• Unlimited generic and brand drugs — copayments apply

• $0 for fitness center membership and fitness classes

• Worldwide emergency care coverage

• A 24-hour healthcare guidance line and more

* You must continue to pay your Medicare Part B premium.

Introduction to the Summary of Benefits for Oxford Medicare Advantage® MosaicSM

You have choices in your healthcare. | As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like OxfordMedicare Advantage Mosaic. You may have other options, too. You make the choice. No matter what you decide, you are still in the Medicare program.

You may join or leave a plan only at certain times. Please call Oxford Medicare Advantage at the telephone number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048.

How can I compare my options? | You can compare our Oxford Medicare Advantage Mosaic plan and the OriginalMedicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit,you can see what our plans cover and what the Original Medicare Plan covers.

Our Members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year.

Where is Oxford Medicare Advantage available? | The service area for this plan includes Bronx, Kings, NewYork, Queens, and Richmond Counties in New York. You must live in one of these places to join the plan. If you are in prison, you can’t join these plans.

Thank you for your interest in Oxford Medicare Advantage Mosaic. Our plans are offered by Oxford Health Plans (NY), Inc.,a Medicare Advantage Health Maintenance Organization (HMO). This Summary of Benefits tells you some features of ourplans. It doesn’t list every service that we cover, every limitation or every exclusion. To get a complete list of our benefits,

please call Oxford Medicare Advantage and ask for the “Evidence of Coverage.”

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Can I choose my doctors? | Oxford Medicare Advantage has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at anytime. You can ask for a current provider directory for an up-to-date list. Our number is listed at the end of this introduction.

What happens if I go to a doctor who’s not in your network? | If you choose to go to a doctor outside our network, you must pay for these services yourself. Neither Oxford Health Plans (NY), Inc. nor the OriginalMedicare Plan will pay for these services.

Where can I get my prescriptions if I join this plan? | Oxford Medicare Advantage has formed a network of pharmacies. You can use any pharmacy in our network. The pharmacies in our network can change at any time. You can ask for a current Pharmacy Network List. Our number is listed at the end of this introduction.

What happens if I go to a pharmacy that’s not in your network? | If you go to a pharmacy that’snot in our network, you might have to pay more for your prescriptions. You also might have to follow special rules before getting your prescription in order for the prescription to be covered under our plan. For more information, call the telephonenumber at the end of this introduction.

Does my plan cover medicare Part B or Part D drugs? | Oxford Medicare Advantage Mosaic does coverboth Medicare Part B prescription drugs and Part D prescription drugs.

Does my plan have a prescription drug formulary? | Oxford Medicare Advantage uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs. The plan may periodically make changes to the formulary. If the formulary changes, affected enrollees will be notified, in writing, before the change is made. Contact OxfordMedicare Advantage Mosaic for details.

What is a medication therapy management (MTM) program? | A Medication TherapyManagement (MTM) Program is a benefit that your plan may offer. You may be identified to participate in a programdesigned for your specific health and pharmacy needs. It is recommended that you take full advantage of this coveredbenefit if you are selected. Contact Oxford Medicare Advantage Mosaic for more details.

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What types of drugs may be covered under Medicare Part B? | The following outpatient prescriptiondrugs may be covered under Medicare Part B. This may include, but is not limited to, the following types of drugs.Contact Oxford Medicare Advantage for more details.

• Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be thepatient) under doctor supervision.

• Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.

• Erythropoietin (Epoetin alpha or Epogen®): By injection if you have end-stage renal disease (permanent kidney failurerequiring either dialysis or transplantation) and need this drug to treat anemia.

• Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.

• Injectable Drugs: Most injectable drugs administered incident to a physician’s service.

• Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for byMedicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.

• Some Oral Cancer Drugs: If the same drug is available in injectable form.

• Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. Inhalation and infusion drugsprovided through durable medical equipment (DME).

Please call Oxford Health Plans (NY), Inc. for more information about this plan. Visit us at www.oxfordmedicare.com or, call us:

Current Members should call 1-800-234-1228 (TTY/TDD: 1-800-201-4874), Monday through Friday, 8:00 AM – 6:00 PM EST for questions related to either the Medicare Advantage program or the Medicare Part D prescription drug program.

Prospective Members should call 1-800-303-6720 (TTY/TDD: 1-800-201-4874), Monday through Friday, 8:00 AM – 5:30 PM EST for questions related to either the Medicare Advantage program or the Medicare Part D prescription drug program.

For more information about Medicare, call 1-800-MEDICARE (1-800-633-4227).TTY users should call 1-800-486-2048. You can call 24 hours a day, seven days a week. Or, visit www.medicare.gov on the web.

If you have special needs, this document may be available in other formats.

PREMIUM AND OTHERIMPORTANT INFORMATION

DOCTOR AND HOSPITAL CHOICE(for more information,

see Emergency andUrgently Needed Care

on page 10)

BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC

You pay the Medicare Part B premium of$88.50 each month.

You may go to any doctor, specialist orhospital that accepts Medicare.

There is no additional premium beyondthe Medicare Part B premium of $78.20each month for your plan benefits andyour Medicare Part D prescription drugbenefits.

You must go to network doctors, specialistsand hospitals.

You do NOT need a referral to go to network doctors, specialists and hospitals

A separate doctor office visit copaymentmay apply for certain services.

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Important Information

INPATIENT HOSPITAL CARE(includes Substance Abuse and

Rehabilitation services)

INPATIENT MENTAL HEALTHCARE


You pay for each benefit period:1

• Days 1-60: an initial deductible of $952

• Days 61-90: $238 each day

• Days 91-150: $476 each lifetime reserve day2

Please call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days.2

You pay the same deductible and copay-ments as inpatient hospital care (above)except Medicare beneficiaries may onlyreceive 190 days in a psychiatric hospi-tal in a lifetime.

There is no copayment for inpatient hospital services received at a networkhospital.

You are covered for unlimited days eachbenefit period.

Except in an emergency, your providermust obtain authorization from OxfordHealth Plans (NY), Inc.

There is no copayment for servicesreceived at a network hospital.

Medicare beneficiaries may only receive190 days in a psychiatric hospital in a lifetime.

Except in an emergency, your providermust obtain authorization from OxfordHealth Plans (NY), Inc.

1 A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit periodbegins.You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

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Inpatient Care

SKILLED NURSING FACILITY(in a Medicare-certifiedskilled nursing facility)

HOME HEALTHCARE(includes medically necessary, intermittent,

skilled nursing care, home health aide services, and rehabilitation services, etc.)

HOSPICE

You pay for each benefit period,1 followingat least a 3-day covered hospital stay:

Days 1-20: $0 for each day

Days 21-100: $119 for each day

There is a limit of 100 days for each benefit period.1

There is no copayment for all coveredhome health visits.

You pay part of the cost for outpatientdrugs and inpatient respite care.

You must receive care from a Medicare-certified hospice.

There is no copayment for servicesreceived at a skilled nursing facility.

No prior hospital stay is required.

You are covered for 100 days each benefit period.1

Authorization rules may apply for services. Contact plan for details.

There is no copayment for Medicare- covered home health visits.


You must receive care from a Medicare-certified hospice.

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1 A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit periodbegins.You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

Inpatient Care

DOCTOR OFFICE VISITS

CHIROPRACTIC SERVICES

PODIATRY SERVICES

You pay 20% of Medicare-approvedamounts.1,2

You are covered for manual manipula-tion of the spine to correct subluxation, provided by chiropractors or other qualified providers.

You pay 100% for routine care.



You are covered for medically necessaryfoot care, including care for medicalconditions affecting the lower limbs.

You pay 100% for routine care.

You pay $0 for each primary care doctoroffice visit for Medicare-covered services.

You pay $5 for each specialist visit forMedicare-covered services.

See Physical Exams (page 17) for moreinformation.

You pay $5 for each Medicare-coveredvisit (manual manipulation of the spineto correct subluxation).

You pay $5 for each Medicare-coveredvisit (medically necessary foot care).

You pay $0 for each routine visit up toone visit every three months.

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1 Each year, you pay a total of one $124 deductible.2 If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more.


Outpatient Care

OUTPATIENT MENTAL HEALTHCARE

OUTPATIENT SUBSTANCE ABUSE CARE

OUTPATIENT SERVICES/SURGERY

AMBULANCE SERVICES(medically necessary ambulance services)

You pay 50% of Medicare-approvedamounts with the exception of certain situations and services for which youpay 20% of approved charges.1,2


You pay 20% of Medicare-approvedamounts for the doctor.1,2

You pay 20% of outpatient facilitycharges.1,2

You pay 20% of Medicare-approvedamounts or applicable fee schedulecharge.1,2

For Medicare-covered mental health services, you pay 50% of the cost foreach individual/group therapy visit.


For Medicare-covered services, you pay$5 for each individual/group visit.

There is no copayment for eachMedicare-covered visit to an ambulatory surgical center.

There is no copayment for eachMedicare-covered visit to an outpatient hospital facility.


There is no copayment for Medicare-covered ambulance services.


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Outpatient Care

EMERGENCY CARE(You may go to any

emergency room if you reasonably believe you need emergency care.)

URGENTLY NEEDED CARE(This is NOT emergency care, and in most cases,

is out of the service area.)

OUTPATIENT REHABILITATION SERVICES(occupational therapy,

physical therapy, speech & language therapy)

You pay 20% of the facility charge orapplicable copayment for each emer-gency room visit; you do NOT pay thisamount if you are admitted to the hos-pital for the same condition within threedays of the emergency room visit.1,2

You pay 20% of doctor charges.1,2

NOT covered outside the U.S. exceptunder limited circumstances.

You pay 20% of Medicare-approvedamounts or applicable copayment.1,2

NOT covered outside the U.S. exceptunder limited circumstances.


You pay $50 for each Medicare-coveredemergency room visit; you do not paythis amount if you are admitted to thehospital within 24 hours for the samecondition.

Worldwide coverage.

You pay $5 for each Medicare-coveredurgently needed care visit.

Worldwide coverage.

You pay $5 for each Medicare-covered occupational therapy visit.

You pay $5 for each Medicare-coveredphysical therapy and/or speech/languagetherapy visit.


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Outpatient Care


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DURABLE MEDICAL EQUIPMENT(includes wheelchairs,

oxygen, etc.)

PROSTHETIC DEVICES(includes braces, artificial limbs

and eyes, etc.)

DIABETES SELF-MONITORING TRAINING AND SUPPLIES

(includes coverage for glucose monitors, test strips, lancets and

self-management training)

DIAGNOSTIC TESTS, X-RAYSAND LAB SERVICES




You pay 20% of Medicare-approvedamounts, except for approved lab services.1,2

There is no copayment for Medicare-approved lab services.

There is no copayment for Medicare-covered items.


There is no copayment for Medicare-covered items.

There is no copayment for diabetes self-monitoring training.

There is no copayment for diabetes supplies.

There is no copayment for the followingMedicare-covered services:

• Clinical/diagnostic lab services

• Radiation therapy

• X-ray visits

Outpatient Care



BONE MASS MEASUREMENT(for people with Medicare

who are at risk)

COLORECTAL SCREENING EXAMS(for people with Medicare,

age 50 and older)

IMMUNIZATIONS(flu vaccine, hepatitis B

vaccine — for people with Medicare who are at risk, pneumonia vaccine)



There is no copayment for the pneumonia and flu vaccines.

You pay 20% of Medicare-approvedamounts for the hepatitis B vaccine.1,2

You may only need the pneumonia vaccine once in your lifetime. Pleasecontact your doctor for details.

There is no copayment for eachMedicare-covered bone mass measurement.

You pay $0 to $5 for each Medicare-covered colorectal screening exam.

You pay $0 to $5 for each additionalscreening exam up to one exam every year.

There is no copayment for the pneumoniaand flu vaccines.

No referral necessary for the Medicare-covered influenza and pneumonia vaccines.

No referral necessary for other immunizations.

There is no copayment for the hepatitisB vaccine.

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Outpatient Medical Services and Supplies



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MAMMOGRAMS (ANNUAL SCREENING)(for women with Medicare,

age 40 and older)

PAP SMEARS AND PELVIC EXAMS(for women with Medicare)

PROSTATE CANCER SCREENING EXAMS(for men with Medicare,

age 50 and older)

You pay 20% of Medicare-approvedamounts.1

No referral necessary for Medicare-covered screenings.

There is no copayment for a Pap smear once every 2 years, or annually for beneficiaries at high risk.1

You pay 20% of Medicare-approvedamounts for pelvic exams.1

There is no copayment for approved lab services and a copayment of 20% ofMedicare-approved amounts for otherrelated services.1

There is no copayment for Medicare-covered screening mammograms.

No referral necessary for Medicare-covered screenings.

There is no copayment for:

• Medicare-covered Pap smears and pelvic exams

• Additional Pap smears and pelvic exams up to one Pap smear and pelvicexam every year

There is no copayment for Medicare-covered prostate cancer screeningexams.

Preventive Services


OUTPATIENT PRESCRIPTION DRUGS You pay 100% for most prescription drugs,unless you enroll in the Medicare Part Dprescription drug program.

This plan uses a formulary. A formularyis a preferred list of drugs selected tomeet patient needs at a lower cost. If theformulary changes, you will be notified,in writing, before the change. To view the plan's formulary, go towww.oxfordmedicare.com on the web.

People who have low incomes, who livein long-term care facilities, or who haveaccess to Indian/Tribal/Urban (IndianHealth Service) facilities may have different out-of-pocket drug costs.Contact the plan for details.

There is no deductible.

Before the total yearly drug costs (paidby both you and your plan) reach$2,250, you pay the following for prescription drugs:

• $3 for a one-month (30-day) supply ofgeneric drugs (Tier 1)

• $28 for a one-month (30-day) supplyof preferred brand drugs (Tier 2)

• $58 for a one-month (30-day) supply of non-preferred brand drugs (Tier 3)

• 25% coinsurance for a one-month (30-day) supply of specialty preferredbrand drugs (Tier 4)

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Preventive Services


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You pay 100% for most prescription drugs,unless you enroll in the Medicare Part Dprescription drug program.

• $9 for a three-month (90-day) supplyof generic drugs (Tier 1)

• $84 for a three-month (90-day) supplyof preferred brand drugs (Tier 2)

• $174 for a for a three-month (90-day)supply of non-preferred brand drugs(Tier 3)

• 25% coinsurance for a three-month (90-day) supply of specialty preferredbrand drugs (Tier 4)

You must use designated retail pharmaciesor mail order to get your prescription drugs.

After the total yearly drug costs (paid byboth you and your plan) reach $2,250,you pay 100% of your prescription drugcosts.

After your yearly out-of-pocket drug costsreach $3,600, you pay the greater of:

• $2 for a generic or preferred brand drugthat is a multi-source drug

• $5 or 5% coinsurance for all other drugs

Certain prescription drugs will have maximum quantity limits. Contact planfor details.

Your provider must get prior authoriza-tion from Oxford Medicare Advantage forcertain prescription drugs. Contact plan fordetails.

OUTPATIENT PRESCRIPTION DRUGS(continued)

Additional Benefits


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DENTAL SERVICES

HEARING SERVICES

In general, you pay 100% for dental services.

You pay 100% for routine hearing examsand hearing aids.

You pay 20% of Medicare-approvedamounts for diagnostic hearing exams.1,2

There is no copayment for the following:

• Oral exams up to one visit every sixmonths

• Cleanings up to one visit every six months

• Fluoride treatments up to one visit every six months

There is no copayment for hearing aids up to one aid every three years.

You pay:

• $5 for each Medicare-covered hearingexam (diagnostic hearing exams)

• $0 for each routine hearing test up toone test every year

• $0 for fitting-evaluation for a hearingaid up to one fittings-evaluations every year

You are covered up to $1,000 for hearingaids every three years.

Additional Benefits



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VISION SERVICES

PHYSICAL EXAMS

You are covered for one pair of eyeglassesor contact lenses after each cataract surgery.1,2

For people with Medicare who are at risk,you are covered for annual glaucomascreenings.1,2

You pay 20% of Medicare-approvedamounts for diagnosis and treatment of diseases and conditions of the eye.1,2

You pay 100% for routine eye exams and glasses.

If your coverage to Medicare Part B beginson or after January 1, 2005, you mayreceive a one time physical exam withinthe first six months of your new Part Bcoverage.

This will not include laboratory tests.Please contact your plan for furtherdetails.

You pay 20% of the Medicare-approvedamount.1

There is no copayment for the followingitems:

• Medicare-covered eye wear (one pair of eyeglasses or contact lenses after each cataract surgery)

• Contacts, limited to one pair of contactsevery two years

• Glasses, limited to one pair of glassesevery two years

You pay $5 for each Medicare-covered eye exam (diagnosis and treatment fordiseases and conditions of the eye).

There is no copayment for routine eyeexams up to one visit every year.

If your coverage to Medicare Part Bbegins on or after January 1, 2005, youmay receive a one time physical examwithin the first six months of your newPart B coverage.

This will not include laboratory tests.Please contact your plan for further details.

There is no copayment for routine physical exams.

You are covered up to one exam every year.

Additional Benefits

You are covered for the following:

• Health education classes

• Newsletter

• Nutritional training

• Congestive heart program

• Health club membership/fitness classes

• Nursing hotline

• Disease management

OXFORD MEDICARE ADVANTAGE MOSAIC

HEALTH/WELLNESS EDUCATION

BENEFIT ORIGINAL MEDICARE

You pay 100%.

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Additional Benefits

Highlights of Benefits

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You’ve worked hard andyou’ve definitely made a difference.

Now it’s time to enjoy all the benefits that life has to offer— including the comprehensive healthcare benefits

you get from Oxford.

You know a thing or two about what it takes to get a job done right. And we do, too. So we rolled up oursleeves and created the Oxford Medicare Advantage Mosaic plan. This plan includes the same benefits offered by traditional Medicare, plus a whole lot more.

For instance, as an Oxford Member, you’ll receive prescription drug coverage,substantial hospitalizationcoverage, worldwide emergency care, plus a list of benefits that traditional Medicare can’t match. Just as important, Oxford’s physician network is extensive — and nearly all physicians are either board-certifiedor board-eligible.

At Oxford, we don’t want you to be concerned about the quality of your healthcare coverage. So we’re offering you the comprehensive benefits that you deserve.

To learn about the individual benefits of the Oxford Medicare Advantage Mosaic plan, please turn the page.

$0 monthly plan premium — you must continue to pay your Medicare Part B premium.

DOCTOR OFFICE VISITS• You must use Oxford participating providers.• You do not pay a copayment when visiting your PCP or OB/GYN.• You pay a $5 copayment when visiting a participating specialist.• There is no charge for annual physicals.• Female Members receive their annual gynecological exam at no charge.

HOSPITAL SERVICES• 100% hospital coverage, as medically necessary. Unlimited days.• $0 deductible.• 100% outpatient ambulatory surgery coverage, as medically necessary.

DIAGNOSTIC TEST, X-RAYS AND LAB SERVICES• There is no copayment for diagnostic radiology services (i.e. X-Rays, CAT Scans, DET Scans, MRIs, etc.).

DENTAL CARE• Preventive and diagnostic dental care, including a dental cleaning every six months, provided by an Oxford

participating primary care dentist is covered at no charge.• Basic dental care, including simple restorative treatment and simple extractions (i.e. silver filling, tooth

covered fillings, etc.), is covered at 70% of the cost when provided by an Oxford participating dentist.• Major dental care, including crowns, dentures, periodontal treatment, endodontics, surgical extractions,

and anesthesia services, is covered at 30% of the cost when provided by an Oxford participating dentist.

OUTPATIENT PRESCRIPTION DRUGS (See Page 24 and 25)

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Oxford Medicare Advantage® MosaicSM

VISION SERVICESWe offer you two ways to receive your vision benefit:Standard Vision Benefit:• Visit any optometrist or ophthalmologist.• Be reimbursed up to $50 per eye exam once every 12 months.• Be reimbursed up to $70 for eyeglasses or contact lenses once every 24 months.Enhanced Vision Benefit:• Visit a participating Davis Vision provider for a vision exam once every12 months at no charge.• Receive one set of eyeglasses or contact lenses once every 24 months at no charge.Eyeglasses Following Cataract Surgery:• Receive eyeglass lenses or contact lenses following each cataract surgery, at no charge.• Be reimbursed up to $55 for frames following each cataract surgery.

HEARING SERVICESStandard Hearing Care Benefit:• Visit an Oxford affiliated audiologist for a hearing exam.• Receive one hearing exam per year; a specialist copayment applies per visit.• Be reimbursed up to $300 for a hearing aid purchased from a supplier of your choice once every 36 months.Enhanced Hearing Care Benefit:• Visit a HearX center for a hearing exam, once every 12 months, at no charge.• Receive a credit of up to $500 toward a hearing aid once every 36 months (when purchased through

a HearX center).• Receive a credit of up to $500 toward a second hearing aid once every 36 months (when purchased

through a HearX center).

PODIATRY SERVICES (ROUTINE CARE)• Visit an Oxford participating podiatrist.• Receive four (4) routine visits (cutting or scraping of nails) at no charge; one per quarter.

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NUTRITION SERVICESThere are two levels of nutrition benefits:• Visit an Oxford affiliated, registered dietitian, once every 12 months, for a preventive nutrition consultation

at no charge.• Visit an Oxford affiliated, registered dietitian, every 12 months, for one intervention visit and one

follow-up visit; a specialist copayment applies per visit.

FITNESS BENEFIT• The SilverSneakers® Fitness program offers access to group exercise classes, aqua aerobics, fitness equipment,

and sauna or steam rooms (where available) at more than 30 convenient locations in New York City.

OXFORD ON-CALL®

• Although your primary care physician is required to provide coverage 24 hours a day, seven days a week, you also have access to healthcare guidance by phone 24 hours a day, 365 days a year.

• Oxford registered nurses ask a series of questions to help identify your symptoms and suggest the most appropriate level of care.

• The registered nurse will provide your primary care physician with a transcript of the call so that he or shecan better manage your care.

EDUCATION AND OUTREACH (E&O)• In addition to our Customer Service Department, we created the E&O Department to meet the special needs

of our Members. The E&O Department is there to provide intensive plan education and solve complex issuesthat may arise. They can also help you access community resources, such as legal, transportation and pharmacy assistance.

OXFORD WALKING CLUB• A regular exercise program is, of course, one of the foundations of good health at any age, and exercise

doesn’t have to be strenuous to be beneficial. With dozens of parks and hundreds of miles of streets available in this area, the Oxford Walking Club is a great way for you to begin or continue an exercise routine. The Oxford Walking Club is also a relaxing way to meet people.

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YOUR PROVIDER MUST PRECERTIFY THE ITEMS LISTED BELOW BY CONTACTING OXFORD MEDICAL MANAGEMENT

CAT scansChiropractic care (treatment plan)

Durable medical equipmentHome health care

Inpatient hospital care1

Inpatient rehabilitationMagnetic Resonance Imaging

Major diagnostic and radiological testingMedicare-covered drugs

MRANuclear medicine

Outpatient mental healthcareOutpatient rehabilitation services Outpatient substance abuse care

Outpatient surgery1

PET scansProsthetic devicesRadiation therapy

Skilled nursing facility careTransplants

1Does not apply to emergency or urgently needed care.

23

Precertification Chart

24

• Medicare Part D is a voluntary prescription drug program available to all Medicare beneficiaries.As a Member of Oxford Medicare Advantage, you will be enrolled in Medicare Part D and you will receive drug coverage based on Oxford’s drug formulary.

• Part D coverage is offered primarily through private companies such as pharmaceuticalcompanies or insurance companies, like Oxford, who offer prescription drug plans or Medicare Advantage plans. Oxford Medicare Advantage is a Medicare Advantage plan that includes Medicare Part D coverage.

• The estimated cost for Part D coverage is approximately $32 per month or $384 per year. As a Member of Oxford Medicare Advantage , you will not be required to pay an additional monthly plan premium for Medicare Part D.

• With Medicare Part D, there is an annual deductible of $250. With Oxford Medicare Advantage,there is no annual deductible, which means you can begin accessing your benefits immediately.

• Medicare Part D provides Medicare beneficiaries who also receive Medicaid benefits with additional prescription drug coverage (i.e. reduced or eliminated premiums, deductibles, copayments or coinsurance, etc.). Oxford Medicare Advantage Select is offered to Medicare beneficiaries who are also eligible for Medicaid benefits. To find out if you qualify for coverage under this plan, contact Oxford at the number listed on the back cover of this Summary of Benefits.

• If your income level falls below $14,355 (individual) or $19,245 (couple) you qualify for reduced premiums, deductibles, copayments and coinsurance under Medicare Part D. Oxford MedicareAdvantage will offer the same level of assistance to low-income Medicare Beneficiaries. For more information, contact Oxford at the number listed on the back cover of this Summary of Benefits.

Part D Prescription Drug Coverage

25

Total DrugExpenditures

Catastrophic Coverage

$5,I00+

Coverage Gap

$2,250

InitialCoverage

$250

AnnualDeductible

$0Monthly

Premium

MEDICARE PART D

You pay the greater of:• $2 copayment or a 5% coinsurance

for multi-source drugs• $5 copayment or a 5% coinsurance

for all others

You pay 100%

You pay 25% Coinsurance

You pay 100%

Approximately $32

OXFORD MEDICARE ADVANTAGE PART D

You pay the greater of:• $2 copayment for multi-source drugs

• $5 copayment or a 5% coinsurancefor all others

You pay 100% (Receive Oxford’s discounted rate bypresenting your Oxford Member IDcard at participating retail pharmacies)

You pay:• $3 for generic drugs;• $28 for preferred brand drugs;• $58 for brand drugs; and• 25% coinsurance for specialty drugs

There is no annual deductible. You pay:• $3 for generic drugs;• $28 for preferred brand drugs;• $58 for brand drugs; and• 25% coinsurance for specialty drugs

$0

Please Note: For prescription drugs obtained out-of-network, you will be reimbursed atour contracted rate minus any applicable copayments.

Part D Prescription Drug Coverage

Members must receive routine carefrom plan providers, be entitled toMedicare Part A and Part B, and continue to pay Medicare premiums.Prescription drugs are subject to limitations. Oxford Health Plans (NY),Inc. is a licensed HMO operating under a Medicare Advantage contract.

l-800-303-6720TDD: l-800-20l-4874

www.oxfordmedicare.com

© 2006 Oxford Health Plans LLC.H3307NY-05-1158 8352

Documents

Oxford Health Plans - New York: Bronx, Kings, New …...York, Queens, and Richmond Counties in New York. You must live in one of these places to join the plan. If you are in prison,