Summary of Benefits New York: Bronx, Kings, New York, Queens and Richmond Counties January 1, 2006 - December 31, 2006
You ve earned the right to live life on your own terms. And that includes the right to affordable healthcare. OXFORD MEDICARE ADVANTAGE MOSAIC SM $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 Mosaic SM 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 our plans. 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. 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 Oxford Medicare 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 Original Medicare 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, 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, you can t join these plans. I
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 any time. 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 Original Medicare 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 s not 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 telephone number at the end of this introduction. Does my plan cover medicare Part B or Part D drugs? Oxford Medicare Advantage Mosaic does cover both 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 Oxford Medicare Advantage Mosaic for details. What is a medication therapy management (MTM) program? A Medication Therapy Management (MTM) Program is a benefit that your plan may offer. You may be identified to participate in a program designed for your specific health and pharmacy needs. It is recommended that you take full advantage of this covered benefit if you are selected. Contact Oxford Medicare Advantage Mosaic for more details. 2
What types of drugs may be covered under Medicare Part B? The following outpatient prescription drugs 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 the patient) 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 failure requiring 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 by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicarecertified 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 drugs provided 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. 3
Important Information BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC PREMIUM AND OTHER IMPORTANT INFORMATION You pay the Medicare Part B premium of $88.50 each month. There is no additional premium beyond the Medicare Part B premium of $78.20 each month for your plan benefits and your Medicare Part D prescription drug benefits. DOCTOR AND HOSPITAL CHOICE (for more information, see Emergency and Urgently Needed Care on page 10) You may go to any doctor, specialist or hospital that accepts Medicare. You must go to network doctors, specialists and hospitals. You do NOT need a referral to go to network doctors, specialists and hospitals A separate doctor office visit copayment may apply for certain services. 5
Inpatient Care BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC INPATIENT HOSPITAL CARE (includes Substance Abuse and Rehabilitation services) 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 day 2 Please call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. 2 There is no copayment for inpatient hospital services received at a network hospital. You are covered for unlimited days each benefit period. Except in an emergency, your provider must obtain authorization from Oxford Health Plans (NY), Inc. INPATIENT MENTAL HEALTHCARE You pay the same deductible and copayments as inpatient hospital care (above) except Medicare beneficiaries may only receive 190 days in a psychiatric hospital in a lifetime. There is no copayment for services received at a network hospital. Medicare beneficiaries may only receive 190 days in a psychiatric hospital in a lifetime. Except in an emergency, your provider must obtain authorization from Oxford Health Plans (NY), Inc. 6 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 period begins.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 BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC SKILLED NURSING FACILITY (in a Medicare-certified skilled nursing facility) You pay for each benefit period, 1 following at 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 services received 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. HOME HEALTHCARE (includes medically necessary, intermittent, skilled nursing care, home health aide services, and rehabilitation services, etc.) There is no copayment for all covered home health visits. There is no copayment for Medicarecovered home health visits. Authorization rules may apply for services. Contact plan for details. HOSPICE You pay part of the cost for outpatient drugs and inpatient respite care. You must receive care from a Medicarecertified hospice. You must receive care from a Medicarecertified hospice. 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 period begins.you must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. 7
Outpatient Care BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC DOCTOR OFFICE VISITS amounts. 1,2 You pay $0 for each primary care doctor office visit for Medicare-covered services. You pay $5 for each specialist visit for Medicare-covered services. See Physical Exams (page 17) for more information. CHIROPRACTIC SERVICES You are covered for manual manipulation of the spine to correct subluxation, provided by chiropractors or other qualified providers. You pay 100% for routine care. amounts. 1,2 You pay $5 for each Medicare-covered visit (manual manipulation of the spine to correct subluxation). PODIATRY SERVICES amounts. 1,2 You are covered for medically necessary foot care, including care for medical conditions affecting the lower limbs. You pay 100% for routine care. You pay $5 for each Medicare-covered visit (medically necessary foot care). You pay $0 for each routine visit up to one visit every three months. 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. 8
Outpatient Care BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC OUTPATIENT MENTAL HEALTHCARE You pay 50% of Medicare-approved amounts with the exception of certain situations and services for which you pay 20% of approved charges. 1,2 For Medicare-covered mental health services, you pay 50% of the cost for each individual/group therapy visit. Authorization rules may apply for services. Contact plan for details. OUTPATIENT SUBSTANCE ABUSE CARE amounts. 1,2 For Medicare-covered services, you pay $5 for each individual/group visit. OUTPATIENT SERVICES/SURGERY amounts for the doctor. 1,2 You pay 20% of outpatient facility charges. 1,2 There is no copayment for each Medicare-covered visit to an ambulatory surgical center. There is no copayment for each Medicare-covered visit to an outpatient hospital facility. Authorization rules may apply for services. Contact plan for details. AMBULANCE SERVICES (medically necessary ambulance services) amounts or applicable fee schedule charge. 1,2 There is no copayment for Medicarecovered ambulance services. 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. 9
Outpatient Care BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC EMERGENCY CARE (You may go to any emergency room if you reasonably believe you need emergency care.) You pay 20% of the facility charge or applicable copayment for each emergency room visit; you do NOT pay this amount if you are admitted to the hospital for the same condition within three days of the emergency room visit. 1,2 You pay 20% of doctor charges. 1,2 NOT covered outside the U.S. except under limited circumstances. You pay $50 for each Medicare-covered emergency room visit; you do not pay this amount if you are admitted to the hospital within 24 hours for the same condition. Worldwide coverage. URGENTLY NEEDED CARE (This is NOT emergency care, and in most cases, is out of the service area.) amounts or applicable copayment. 1,2 NOT covered outside the U.S. except under limited circumstances. You pay $5 for each Medicare-covered urgently needed care visit. Worldwide coverage. OUTPATIENT REHABILITATION SERVICES (occupational therapy, physical therapy, speech & language therapy) amounts. 1,2 You pay $5 for each Medicare-covered occupational therapy visit. You pay $5 for each Medicare-covered physical therapy and/or speech/language therapy visit. 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. I0
Outpatient Care BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC DURABLE MEDICAL EQUIPMENT (includes wheelchairs, oxygen, etc.) amounts. 1,2 There is no copayment for Medicarecovered items. Authorization rules may apply for services. Contact plan for details. PROSTHETIC DEVICES (includes braces, artificial limbs and eyes, etc.) amounts. 1,2 There is no copayment for Medicarecovered items. DIABETES SELF-MONITORING TRAINING AND SUPPLIES (includes coverage for glucose monitors, test strips, lancets and self-management training) amounts. 1,2 There is no copayment for diabetes self-monitoring training. There is no copayment for diabetes supplies. DIAGNOSTIC TESTS, X-RAYS AND LAB SERVICES amounts, except for approved lab services. 1,2 There is no copayment for Medicareapproved lab services. There is no copayment for the following Medicare-covered services: Clinical/diagnostic lab services Radiation therapy X-ray visits 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. II
Outpatient Medical Services and Supplies BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC BONE MASS MEASUREMENT (for people with Medicare who are at risk) amounts. 1,2 There is no copayment for each Medicare-covered bone mass measurement. COLORECTAL SCREENING EXAMS (for people with Medicare, age 50 and older) amounts. 1,2 You pay $0 to $5 for each Medicarecovered colorectal screening exam. You pay $0 to $5 for each additional screening exam up to one exam every year. 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. amounts for the hepatitis B vaccine. 1,2 You may only need the pneumonia vaccine once in your lifetime. Please contact your doctor for details. There is no copayment for the pneumonia and flu vaccines. No referral necessary for the Medicarecovered influenza and pneumonia vaccines. No referral necessary for other immunizations. There is no copayment for the hepatitis B vaccine. 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. I2
Preventive Services BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC MAMMOGRAMS (ANNUAL SCREENING) (for women with Medicare, age 40 and older) amounts. 1 No referral necessary for Medicarecovered screenings. There is no copayment for Medicarecovered screening mammograms. No referral necessary for Medicarecovered screenings. PAP SMEARS AND PELVIC EXAMS (for women with Medicare) There is no copayment for a Pap smear once every 2 years, or annually for beneficiaries at high risk. 1 amounts for pelvic exams. 1 There is no copayment for: Medicare-covered Pap smears and pelvic exams Additional Pap smears and pelvic exams up to one Pap smear and pelvic exam every year PROSTATE CANCER SCREENING EXAMS (for men with Medicare, age 50 and older) There is no copayment for approved lab services and a copayment of 20% of Medicare-approved amounts for other related services. 1 There is no copayment for Medicarecovered prostate cancer screening exams. 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. I3
Preventive Services BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC OUTPATIENT PRESCRIPTION DRUGS You pay 100% for most prescription drugs, unless you enroll in the Medicare Part D prescription drug program. This plan uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified, in writing, before the change. To view the plan's formulary, go to www.oxfordmedicare.com on the web. People who have low incomes, who live in long-term care facilities, or who have access to Indian/Tribal/Urban (Indian Health 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 (paid by both you and your plan) reach $2,250, you pay the following for prescription drugs: $3 for a one-month (30-day) supply of generic drugs (Tier 1) $28 for a one-month (30-day) supply of 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 preferred brand drugs (Tier 4) I4
Additional Benefits BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC OUTPATIENT PRESCRIPTION DRUGS (continued) You pay 100% for most prescription drugs, unless you enroll in the Medicare Part D prescription drug program. $9 for a three-month (90-day) supply of generic drugs (Tier 1) $84 for a three-month (90-day) supply of 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 preferred brand drugs (Tier 4) You must use designated retail pharmacies or mail order to get your prescription drugs. After the total yearly drug costs (paid by both you and your plan) reach $2,250, you pay 100% of your prescription drug costs. After your yearly out-of-pocket drug costs reach $3,600, you pay the greater of: $2 for a generic or preferred brand drug that is a multi-source drug $5 or 5% coinsurance for all other drugs Certain prescription drugs will have maximum quantity limits. Contact plan for details. Your provider must get prior authorization from Oxford Medicare Advantage for certain prescription drugs. Contact plan for details. I5
Additional Benefits BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC DENTAL SERVICES In general, you pay 100% for dental services. There is no copayment for the following: Oral exams up to one visit every six months Cleanings up to one visit every six months Fluoride treatments up to one visit every six months HEARING SERVICES You pay 100% for routine hearing exams and hearing aids. amounts for diagnostic hearing exams. 1,2 There is no copayment for hearing aids up to one aid every three years. You pay: $5 for each Medicare-covered hearing exam (diagnostic hearing exams) $0 for each routine hearing test up to one test every year $0 for fitting-evaluation for a hearing aid up to one fittings-evaluations every year You are covered up to $1,000 for hearing aids every three years. 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. I6
Additional Benefits BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC VISION SERVICES You are covered for one pair of eyeglasses or contact lenses after each cataract surgery. 1,2 For people with Medicare who are at risk, you are covered for annual glaucoma screenings. 1,2 amounts for diagnosis and treatment of diseases and conditions of the eye. 1,2 You pay 100% for routine eye exams and glasses. There is no copayment for the following items: Medicare-covered eye wear (one pair of eyeglasses or contact lenses after each cataract surgery) Contacts, limited to one pair of contacts every two years Glasses, limited to one pair of glasses every two years You pay $5 for each Medicare-covered eye exam (diagnosis and treatment for diseases and conditions of the eye). There is no copayment for routine eye exams up to one visit every year. PHYSICAL EXAMS If your coverage to Medicare Part B begins on or after January 1, 2005, you may receive a one time physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details. You pay 20% of the Medicare-approved amount. 1 If your coverage to Medicare Part B begins on or after January 1, 2005, you may receive a one time physical exam within the first six months of your new Part 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. I7
Additional Benefits BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE MOSAIC HEALTH/WELLNESS EDUCATION You pay 100%. You are covered for the following: Health education classes Newsletter Nutritional training Congestive heart program Health club membership/fitness classes Nursing hotline Disease management I8
Highlights of Benefits You ve worked hard and you 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 our sleeves 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 hospitalization coverage, 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-certified or 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. l9
Oxford Medicare Advantage Mosaic SM $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) 20
Oxford Medicare Advantage Mosaic SM VISION SERVICES We 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 SERVICES Standard 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. 2I
Oxford Medicare Advantage Mosaic SM NUTRITION SERVICES There 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 she can 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 issues that 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. 22
Precertification Chart YOUR PROVIDER MUST PRECERTIFY THE ITEMS LISTED BELOW BY CONTACTING OXFORD MEDICAL MANAGEMENT CAT scans Chiropractic care (treatment plan) Durable medical equipment Home health care Inpatient hospital care 1 Inpatient rehabilitation Magnetic Resonance Imaging Major diagnostic and radiological testing Medicare-covered drugs MRA Nuclear medicine Outpatient mental healthcare Outpatient rehabilitation services Outpatient substance abuse care Outpatient surgery 1 PET scans Prosthetic devices Radiation therapy Skilled nursing facility care Transplants 1 Does not apply to emergency or urgently needed care. 23
Part D Prescription Drug Coverage 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 pharmaceutical companies 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 Medicare Advantage 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. 24
Part D Prescription Drug Coverage Total Drug Expenditures Catastrophic Coverage $5,I00+ Coverage Gap $2,250 Initial Coverage $250 Annual Deductible $0 Monthly 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% coinsurance for all others You pay 100% (Receive Oxford s discounted rate by presenting your Oxford Member ID card 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 at our contracted rate minus any applicable copayments. 25
Members must receive routine care from plan providers, be entitled to Medicare 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-800-303-6720 TDD: l-800-20l-4874 www.oxfordmedicare.com H3307 NY-05-1158 8352 2006 Oxford Health Plans LLC.