Summary of Benefits. New York: Bronx, Kings, New York, Queens and Richmond Counties

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 ESSENTIAL SM $0 monthly plan premium.* No referrals required. Coverage provided for visits to your primary care physician and inpatient hospitalization visits copayments apply. A 24-hour healthcare guidance line and more. OXFORD MEDICARE ADVANTAGE SIGNATURE SM $0 monthly plan premium.* No referrals required. Coverage provided for visits to your primary care physician and inpatient hospitalization visits copayments apply. Unlimited generic and brand drugs copayments apply. A 24-hour healthcare guidance line and more. OXFORD MEDICARE ADVANTAGE BALANCE SM $0 monthly plan premium.* No referrals required. Coverage provided for visits to your primary care physician copayments apply. Unlimited generic and brand drugs copayments apply. There is a $1,500 deductible for certain medical services. A 24-hour healthcare guidance line and more. OXFORD MEDICARE ADVANTAGE SELECT SM $0 monthly plan premium.* No referrals required. No copayments for visits to your primary care physician or inpatient hospitalization visits. Unlimited generic and brand drugs copayments apply. A 24-hour healthcare guidance line and more. Please note: This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. *You must continue to pay your Medicare Part B premium.

Introduction to the Summary of Benefits for Oxford Medicare Advantage Thank you for your interest in Oxford Medicare Advantage. 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 Essential SM, Oxford Medicare Advantage Balance SM, Oxford Medicare Advantage Signature SM, or Oxford Medicare Advantage Select SM (Special Needs Plan). The Select Plan is designed for people who meet specific enrollment criteria. Call Oxford Medicare Advantage to find out if you are eligible to join. Our number is listed at the end of this introduction. 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 plans 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 these plans is Bronx, Kings, New York, Queens, and Richmond Counties in New York. You must live in one of these places to join a plan listed in this Summary of Benefits. Please note: the Oxford Medicare Advantage Balance plan is not available in Bronx County. 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 Signature, Oxford Medicare Advantage Balance and Oxford Medicare Advantage Select Cover both Medicare Part B prescription drugs and Part D prescription drugs. Oxford Medicare Advantage Essential covers Medicare Part B prescription drugs, however, it does not cover Medicare 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. Please note: Oxford Medicare Advantage Essential does not cover Medicare Part D prescription drugs. Contact Oxford Medicare Advantage 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. Please note: Oxford Medicare Advantage Essential does not cover Medicare Part D prescription drugs. Contact Oxford Medicare Advantage 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 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 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 from 8:00 AM to 6:00 PM, 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 from 8:00 AM to 5:30 PM, 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 ESSENTIAL 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 $88.50 each month. DOCTOR AND HOSPITAL CHOICE (for more information, see Emergency and Urgently Needed Care on page 14) 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. 4

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* There is no additional premium beyond the Medicare Part B premium of $88.50 each month for your plan benefits and your Medicare Part D prescription drug benefits. There is no additional premium beyond the Medicare Part B premium of $88.50 each month for your plan benefits and your Medicare Part D prescription drug benefits. You pay a $1,500 yearly deductible for the following plan services when received in network only: - Inpatient hospital care - Inpatient mental health care - Skilled nursing facility - Home health care - Outpatient services/surgery - Ambulance services - Durable medical equipment - Prosthetic devices - Outpatient prescription drugs - Partial hospitalization - Renal dialysis There is no additional premium beyond the Medicare Part B premium of $88.50 each month for your plan benefits and your Medicare Part D prescription drug benefits. 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. 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. 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. * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. 5

Inpatient Care BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL 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 You pay for each Medicare-covered stay at a network hospital: Days 1-10: $80 each day Days 11-90: $0 each day There is no copayment for additional days received at a network hospital. There is a $800 maximum out-of-pocket limit every stay. 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 there is a 190-day lifetime limit in a psychiatric hospital. You pay for each Medicare-covered stay at a network hospital: Days 1-10: $80 each day Days 11-90: $0 each day There is a $800 maximum out-of-pocket limit for every hospital stay. 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. 2 Lifetime reserve days can only be used once.

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* You pay for each Medicare-covered stay at a network hospital: Days 1-7: $125 each day Days 8-90: $0 each day There is no copayment for additional days received at a network hospital. There is a $875 maximum out-of-pocket limit every stay. You are covered for unlimited days each benefit period. Except in an emergency, your provider must obtain authorization from Oxford Health Plans (NY), Inc. 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. 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. You pay for each Medicare-covered stay at a network hospital: Days 1-7: $125 each day Days 8-90: $0 each day There is a $875 maximum out-of-pocket limit for every hospital stay. 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. 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. 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. * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. 7

Inpatient Care BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL 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 You pay $0 each day for days 1-10 for a stay at a skilled nursing facility. You pay $75 each day for days 11-100 for a stay 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. 8 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.

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* You pay $0 each day for day(s) 1-5 for a stay at a skilled nursing facility. You pay $125 each day for day(s) 6-100 for a stay 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 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. 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. There is no copayment for Medicarecovered home health visits. Authorization rules may apply for services. Contact plan for details. There is no copayment for Medicarecovered home health visits. Authorization rules may apply for services. Contact plan for details. There is no copayment for Medicarecovered home health visits. Authorization rules may apply for services. Contact plan for details. You must receive care from a Medicarecertified hospice. You must receive care from a Medicarecertified hospice. You must receive care from a Medicarecertified hospice. * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. 9

Outpatient Care BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL DOCTOR OFFICE VISITS You pay 20% of Medicare-approved amounts. 1,2 You pay $10 for each primary care doctor office visit for Medicare-covered services. You pay $20 for each specialist visit for Medicare-covered services. See Physical Exams (page 28) 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. You pay 20% of Medicare-approved amounts. 1,2 You pay $20 for each Medicare-covered visit (manual manipulation of the spine to correct subluxation). Authorization rules may apply for services. Contact plan for details. PODIATRY SERVICES You pay 20% of Medicare-approved 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 $20 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. l0

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* You pay $15 for each primary care doctor office visit for Medicare-covered services. You pay $25 for each specialist visit for Medicare-covered services. See Physical Exams (page 28) for more information. You pay $10 for each primary care doctor office visit for Medicare-covered services. You pay $20 for each specialist visit for Medicare-covered services. See Physical Exams (page 28) for more information. There is no copayment for each primary care doctor office visit for Medicarecovered services. You pay $10 for each specialist visit for Medicare-covered services. See Physical Exams (page 28) for more information. You pay $25 for each Medicare-covered visit (manual manipulation of the spine to correct subluxation). Authorization rules may apply for services. Contact plan for details. You pay $20 for each Medicare-covered visit (manual manipulation of the spine to correct subluxation). Authorization rules may apply for services. Contact plan for details. You pay $10 for each Medicare-covered visit (manual manipulation of the spine to correct subluxation). Authorization rules may apply for services. Contact plan for details. You pay $25 for each Medicare-covered visit (medically necessary foot care). You pay $0 for each routine visit up to one visit every three months. You pay $20 for each Medicare-covered visit (medically necessary foot care). You pay $0 for each routine visit up to one visit every three months. You pay $10 for each Medicare-covered visit (medically necessary foot care). You pay $0 for each routine visit up to one visit every three months. * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. ll

Outpatient Care BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL 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. OUTPATIENT SUBSTANCE ABUSE CARE You pay 20% of Medicare-approved amounts. 1,2 For Medicare-covered services, you pay $20 for each individual/group visit. Except in an emergency, your provider must obtain authorization from Oxford Health Plans (NY), Inc. OUTPATIENT SERVICES/SURGERY You pay 20% of Medicare-approved amounts for the doctor. 1,2 You pay 20% of outpatient facility charges. 1,2 You pay $100 for each Medicare-covered visit to an ambulatory surgical center. You pay $100 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) You pay 20% of Medicare-approved 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. l2

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* For Medicare-covered mental health services, you pay 50% of the cost for each individual/group therapy visit. For Medicare-covered mental health services, you pay 50% of the cost for each individual/group therapy visit. For Medicare-covered Mental Health services, you pay $20 for each individual/group therapy visit. For Medicare-covered services, you pay $25 for each individual/group visit. Except in an emergency, your provider must obtain authorization from Oxford Health Plans (NY), Inc. For Medicare-covered services, you pay $20 for each individual/group visit. Except in an emergency, your provider must obtain authorization from Oxford Health Plans (NY), Inc. For Medicare-covered services, you pay $10 for each individual/group visit. Except in an emergency, your provider must obtain authorization from Oxford Health Plans (NY), Inc. You pay $300 for each Medicare-covered visit to an ambulatory surgical center. You pay $300 for each Medicare-covered visit to an outpatient hospital facility. Authorization rules may apply for services. Contact plan for details. 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. 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. You pay 20% of the cost for Medicarecovered ambulance services. There is no copayment for Medicarecovered ambulance services. There is no copayment for Medicarecovered ambulance services. * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. l3

Outpatient Care BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL 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.) You pay 20% of Medicare-approved amounts or applicable copayment. 1,2 NOT covered outside the U.S. except under limited circumstances. You pay $20 for each Medicare-covered urgently needed care visit. Worldwide coverage. OUTPATIENT REHABILITATION SERVICES (occupational therapy, physical therapy, speech and language therapy) You pay 20% of Medicare-approved amounts. 1,2 You pay $20 for each Medicare-covered occupational therapy visit. You pay $20 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. l4

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* 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. 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. 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. You pay $25 for each Medicare-covered urgently needed care visit. Worldwide coverage. You pay $20 for each Medicare-covered urgently needed care visit. Worldwide coverage. You pay $10 for each Medicare-covered urgently needed care visit. Worldwide coverage. You pay $25 for each Medicare-covered occupational therapy visit. You pay $25 for each Medicare-covered physical therapy and/or speech/language therapy visit. You pay $20 for each Medicare-covered occupational therapy visit. You pay $20 for each Medicare-covered physical therapy and/or speech/language therapy visit. You pay $10 for each Medicare-covered occupational therapy visit. You pay $10 for each Medicare-covered physical therapy and/or speech/language therapy visit. * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. l5

Outpatient Medical Services and Supplies BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL DURABLE MEDICAL EQUIPMENT (includes wheelchairs, oxygen, etc.) You pay 20% of Medicare-approved 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.) You pay 20% of Medicare-approved amounts. 1,2 There is no copayment for Medicarecovered items. Authorization rules may apply for services. Contact plan for details. DIABETES SELF-MONITORING TRAINING AND SUPPLIES (includes coverage for glucose monitors, test strips, lancets and self-management training) You pay 20% of Medicare-approved 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 You pay 20% of Medicare-approved 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 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. l6

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* There is no copayment for Medicarecovered items. Authorization rules may apply for services. Contact plan for details. There is no copayment for Medicarecovered items. Authorization rules may apply for services. Contact plan for details. There is no copayment for Medicarecovered items. Authorization rules may apply for services. Contact plan for details. There is no copayment for Medicarecovered items. Authorization rules may apply for services. Contact plan for details. There is no copayment for Medicarecovered items. Authorization rules may apply for services. Contact plan for details. There is no copayment for Medicarecovered items. Authorization rules may apply for services. Contact plan for details. There is no copayment for diabetes self-monitoring training. There is no copayment for diabetes supplies. There is no copayment for diabetes self-monitoring training. There is no copayment for diabetes supplies. There is no copayment for diabetes self-monitoring training. There is no copayment for diabetes supplies. There is no copayment for the following Medicare-covered services: Clinical/diagnostic lab services Radiation therapy You pay 20% of the cost for each Medicare-covered X-ray visit. There is no copayment for the following Medicare-covered services: Clinical/diagnostic lab services Radiation therapy X-ray visits There is no copayment for the following Medicare-covered services: Clinical/diagnostic lab services Radiation therapy X-ray visit * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. l7

Preventive Services BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL BONE MASS MEASUREMENT (for people with Medicare who are at risk) You pay 20% of Medicare-approved 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) You pay 20% of Medicare-approved amounts. 1,2 You pay $10 to $20 for each Medicarecovered colorectal screening exam. You pay $10 to $20 for each additional screening exam up to one exam every year. An additional facility charge may be included in the cost for services. 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-approved 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. l8

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* There is no copayment for each Medicare-covered bone mass measurement. There is no copayment for each Medicare-covered bone mass measurement. There is no copayment for each Medicare-covered bone mass measurement. You pay $15 to $25 for each Medicarecovered colorectal screening exam. You pay $15 to $25 for each additional screening exam up to one exam each year. An additional facility charge may be included in the cost for services. You pay $10 to $20 for each Medicarecovered colorectal screening exam. You pay $10 to $20 for each additional screening exam up to one exam every year. You pay $0 to $10 for each Medicarecovered colorectal screening exam. You pay $0 to $10 for each additional screening exam up to one exam every year. 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. 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. 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. * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. l9

Preventive Services BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL MAMMOGRAMS (ANNUAL SCREENING) (for women with Medicare age 40 and older) You pay 20% of Medicare-approved 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, annually for beneficiaries at high risk. 1 You pay 20% of Medicare-approved 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 If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more. 20

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* There is no copayment for Medicarecovered screening mammograms. No referral necessary for Medicarecovered screenings. There is no copayment for Medicarecovered screening mammograms. No referral necessary for Medicarecovered screenings. There is no copayment for Medicarecovered screening mammograms. No referral necessary for Medicarecovered 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 pelvic exam every year 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 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 There is no copayment for Medicarecovered prostate cancer screening exams. There is no copayment for Medicarecovered prostate cancer screening exams. There is no copayment for Medicarecovered prostate cancer screening exams. * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. 2l

Additional Benefits BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL OUTPATIENT PRESCRIPTION DRUGS You pay 100% for most prescription drugs, unless you enroll in the Medicare Part D prescription drug program. You pay 100% for most prescription drugs. This plan does not cover Medicare Part D prescription drugs. 22

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* 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) 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) 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) * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. 23

Additional Benefits BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL OUTPATIENT PRESCRIPTION DRUGS (continued) You pay 100% for most prescription drugs, unless you enroll in the Medicare Part D prescription drug program. See previous page for prescription drug coverage. 24

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* $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. $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. $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. Please note: This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. 25

Additional Benefits BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL 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. You pay 20% of Medicare-approved amounts for diagnostic hearing exams. 1,2 There is no copayment for hearing aids up to one aid every three years. You pay: $20 for each Medicare-covered hearing exam (diagnostic hearing exams) $0 for each routine hearing test up to one test every year $0 for fittings-evaluations for a hearing aid up to one fitting-evaluation every year You are covered up to $1,000 for hearing aids every three years. 26

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* 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 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 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 There is no copayment for hearing aids up to one aid every three years. You pay: $25 for each Medicare-covered hearing exam (diagnostic hearing exams) $0 for each routine hearing test up to one test every year $0 for fittings-evaluations for a hearing aid up to one fitting-evaluation every year You are covered up to $1,000 for hearing aids every three years. There is no copayment for hearing aids up to one aid every three years. You pay: $20 for each Medicare-covered hearing exam (diagnostic hearing exams) $0 for each routine hearing test up to one test every year $0 for fittings-evaluations for a hearing aid up to one fitting-evaluation every year You are covered up to $1,000 for hearing aids every three years. There is no copayment for hearing aids up to one aid every three years. You pay: $10 for each Medicare-covered hearing exam (diagnostic hearing exams) $0 for each routine hearing test up to one test every year $0 for fittings-evaluations for a hearing aid up to one fitting-evaluation every year You are covered up to $1,000 for hearing aids every three years. * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. 27

Additional Benefits BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL 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 You pay 20% of Medicare-approved 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 $20 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. 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. 28

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* 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 $25 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. 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 $20 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. 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 $10 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. 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. 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. 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. * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. 29

Additional Benefits BENEFIT ORIGINAL MEDICARE OXFORD MEDICARE ADVANTAGE ESSENTIAL 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 30

OXFORD MEDICARE ADVANTAGE SIGNATURE OXFORD MEDICARE ADVANTAGE BALANCE OXFORD MEDICARE ADVANTAGE SELECT* You are covered for the following: Health education classes Newsletter Nutritional training Congestive heart program Health club membership/fitness classes Nursing hotline Disease management You are covered for the following: Health education classes Newsletter Nutritional training Congestive heart program Health club membership/fitness classes Nursing hotline Disease management You are covered for the following: Health education classes Newsletter Nutritional training Congestive heart program Health club membership/fitness classes Nursing hotline Disease management * This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. 3I

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 four Oxford Medicare Advantage plans. Each one 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 our individual benefits and the new Medicare Part D prescription drug coverage, please turn the page. 33

Benefits and services for all four plans. The following benefits apply to all four Oxford Medicare Advantage plans. 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 every 12 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 following each cataract surgery at no charge. Be reimbursed up to $55 for frames following each cataract surgery. HEARING SERVICES We also offer you two ways to receive your hearing care benefit: 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). 34

Benefits and services for all four plans. The following benefits apply to all four Oxford Medicare Advantage plans. DENTAL CARE Preventive and diagnostic dental care, including a dental cleaning provided by an Oxford participating primary care dentist covered at no charge. 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. 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 no charge. 35

Benefits and services for all four plans. The following benefits apply to all four Oxford Medicare Advantage plans. OXFORD ON-CALL Although your primary care physician is required to provide coverage 24 hours a day, 7 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 Member Services 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. HEALTH PROMOTION SEMINARS Throughout the year, we will invite you to attend free health education seminars led by registered nurses, dietitians, and exercise physiologists, on topics such as managing medications, pain management, herbal remedies, and complementary care. Additionally, we offer chronic disease self-management workshops for Members who are identified as having diabetes or chronic lung conditions. 36

Oxford Medicare Advantage Essential SM The following benefits apply to the Oxford Medicare Advantage Essential plan only. $0 monthly plan premium you must continue to pay your Medicare Part B premium. DOCTOR OFFICE VISITS You must use Oxford participating providers. You pay a $10 copayment when visiting your PCP or OB/GYN. You pay a $20 copayment when visiting a participating specialist. Female Members receive their annual gynecological exam at no charge. HOSPITAL CARE There is a $80 inpatient facility copayment per day not to exceed $800 per hospital stay. There is a $100 facility copayment for each outpatient hospital surgery or ambulatory surgery. 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.). OUTPATIENT PRESCRIPTION DRUGS You pay 100% for most prescription drugs. This plan does not cover Medicare Part D prescription drugs. 37

Oxford Medicare Advantage Signature SM The following benefits apply to the Oxford Medicare Advantage Signature plan only. $0 monthly plan premium you must continue to pay your Medicare Part B premium. DOCTOR OFFICE VISITS You must use Oxford participating providers. You pay a $15 copayment when visiting your PCP or OB/GYN there is no charge for annual physicals. You pay a $25 copayment when visiting a participating specialist. Female Members receive their annual gynecological exam at no charge. HOSPITAL CARE There is a $125 inpatient facility copayment per day not to exceed $875 per hospital stay. There is a $250 physician copayment for each inpatient surgery. There is a $300 facility copayment for each outpatient hospital surgery or ambulatory surgery. There is a $200 physician copayment for each outpatient hospital surgery or ambulatory surgery. DIAGNOSTIC TESTS, X-RAYS AND LAB TESTS You pay 20% of the cost of diagnostic radiology services. (i.e., X-Rays, CAT Scans, PET Scans, MRIs, etc.). OUTPATIENT PRESCRIPTION DRUGS (See pages 42 and 43) 38

Oxford Medicare Advantage Balance SM The following benefits apply to the Oxford Medicare Advantage Balance plan only. $0 monthly plan premium you must continue to pay your Medicare Part B premium. DOCTOR OFFICE VISITS You must use Oxford participating providers. You pay a $10 copayment when visiting your PCP or OB/GYN there is no charge for annual physicals. You pay a $20 copayment when visiting a participating specialist. Female Members receive their annual gynecological exam at no charge. IN-NETWORK DEDUCTIBLE There is a $1,500 deductible for certain services.* The deductible is the amount of the bill which you, the Member, are responsible for after Oxford has paid $500 toward certain medical services. The $1,500 deductible amount applies to all covered Oxford Medicare Advantage Balance benefits except the following: Allergy testing and treatment Outpatient therapy Additional Oxford benefits and Chiropractic services Physician office visits services (hearing, vision, podiatry Diabetic Supplies Physical therapy visits, visits, nutrition nutrition visits, visits, exercise exercise and and and fitness classes, worldwide Emergency room Speech therapy emergency and fitness care, classes, non-medicare worldwide Immunizations Therapeutic injections covered emergency drugs, care, and non-medicare dental services) In-office surgery Urgent care covered drugs, and dental services) Outpatient mental health Please note: Certain copayments may apply to some of the benefits listed above. 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.). OUTPATIENT PRESCRIPTION DRUGS (See pages 42 and 43) *Your coverage is based on the calendar year. The $1,500 deductible is prorated. If your membership becomes effective after June 30, your deductible is $750 after Oxford has paid $250 toward certain medical services. The deductible terminates at the end of the calendar year regardless of when your membership becomes effective and of whether your deductible has been met. 39

Oxford Medicare Advantage Select SM The following benefits apply to the Oxford Medicare Advantage Select plan only. This plan is only available to individuals who are eligible for both Medicare and Medicaid benefits. $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 $10 copayment when visiting a participating specialist. Female Members receive their annual gynecological exam at no charge. There is no charge for annual physicals. HOSPITAL CARE 100% hospital coverage as medically necessary. 100% outpatient ambulatory surgery coverage. DIAGNOSTIC TESTS, X-RAYS AND LAB TESTS There is no copayment for diagnostic radiology services (i.e., X-Rays, CAT Scans, DET Scans, MRIs, etc.). OUTPATIENT PRESCRIPTION DRUGS (See pages 41 through 43) 40

Oxford Medicare Advantage Select SM The following benefits apply to the Oxford Medicare Advantage Select plan only. Monthly Premium Annual Deductible Coverage Gap You pay: You pay: Annual income up to $9,570 (single) or $12,830 (married) and you were enrolled in Medicaid with prescription drug benefits in 2005 $0 $0 None $1 for generic and preferred multi-source drugs $3 for all others $0 after $3,600 out-of-pocket expense is met Annual income above $9,570 and below $12,920 (single) or above $12,830 and below $17,321 (married) and you were enrolled in Medicaid with prescription drug benefits in 2005 $0 $0 None $2 for generic and preferred multi-source drugs $5 for all others $0 after $3,600 out-of-pocket expense is met Annual income below $12,920 and assets* below $6,000 (single) or annual income below $17,321 and assets* below $9,000 (married) Annual income below $12,920 and assets* below $10,000 (single) or annual income below $19,245 and assets* below $20,000 (married) $0 $0 None $2 for generic and preferred multi-source drugs $5 for all others $0 $0 None The lesser of the assigned copayment or 15% coinsurance for both generic and brand name drugs $0 after $3,600 out-of-pocket expense is met After $3,600 out-ofpocket, you pay: $2 for generic and preferred multi-source drugs $5 for all others * For a comprehensive list of eligibility requirements, contact your local Social Security Administration office. 4I

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. 42 *Oxford Medicare Advantage Essential does not offer Part D prescription drug coverage. If you choose this plan you will be choosing to forego Part D drug coverage.

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. 43

Precertification Chart The items listed below refer to all four plans. 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. 44

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-05-1159 8353 2006 Oxford Health Plans LLC.