GIVING MEDICARE BENEFICIARIES THE BENEFITS THEY DESERVE.

Transcription

1 GIVING MEDICARE BENEFICIARIES THE BENEFITS THEY DESERVE.

2 OXFORD MEDICARE ADVANTAGE Since 1992, Oxford Health Plans has offered Medicare beneficiaries a comprehensive, affordable alternative to traditional Medicare through its Oxford Medicare Advantage plans. Currently, Oxford offers healthcare coverage to over 70,000 Medicare beneficiaries throughout the tri-state area. OXFORD MEDICARE ADVANTAGE INDIVIDUAL PLANS The comparison charts inside this packet provide an overview of the individual plans being offered in Bronx, Kings, Queens, New York, Orange, Richmond, Rockland and Westchester counties in New York and Bergen, Essex, Hudson, Mercer, Middlesex, Monmouth, Ocean, Pasaic and Union counties in New Jersey as they compare to Original Medicare. OXFORD MEDICARE ADVANTAGE GROUP PLANS Oxford also offers Medicare group plans to groups with a minimum of 2 eligible retirees in our service area. Groups have two options when it comes to offering Oxford Medicare Advantage to their retirees: 1. Groups can offer the Oxford Medicare Advantage Signature and/or Oxford Medicare Advantage Balance SM (varies by service area) individual plan to their retirees. If groups choose this option, they are not charged any premiums. 2. Groups can add medical and prescription drug riders (listed on the back page) to the Oxford Medicare Advantage Signature or Oxford Medicare Advantage Balance SM (varies by service area) individual plan for an additional premium. If groups choose to add these riders, the plan must be an employer-sponsored plan and have a minimum of 50% employer contribution if the premium is $80 or more. This also accounts for 25% employer contribution if the premium is less than $80. 1 In Connecticut, Oxford has an enrollment capacity which may limit enrollment in the Individual Plan. 2 Effective January 1, 2005, this plan will be closed for enrollment in Queens, Richmond and New York counties, with limited exceptions (i.e., enrollment during a special election period). 3 The Oxford Medicare Advantag Balance plan is not available in Bronx County. ADDITIONAL INFORMATION ABOUT OXFORD MEDICARE ADVANTAGE GROUP PLANS A Medicare group plan can be purchased from Oxford, even if the group is not currently an Oxford commercial customer. Rates for this group will be quoted on a two-tier basis (single and double) with the double rate being two times the single rate. If a group wishes to cover spouses and dependents of Medicare- eligible retirees who are under the age of 65, the group must have at least 250 enrolled Oxford commercial Members and more than 75% participation in the group. If quoting on both the active (commercial) and Medicare-eligible population, the active rates cannot be blended with the Medicare rates. OXFORD MEDICARE ADVANTAGE PHYSICIAN NETWORK Oxford Medicare Advantage individual and group plan Members have access to the entire Oxford Medicare Advantage provider network in Bronx, Kings, Queens, Nassau, New York, Orange, Richmond, Rockland and Westchester counties in New York; Bergen, Essex, Hudson, Mercer, Middlesex, Monmouth, Ocean, Passaic and Union counties in New Jersey; and New Haven County in Connecticut. Today, our Medicare provider network consists of over 29,000 primary care physicians (PCP) and specialists in the tristate area. For more information about how Oxford Medicare Advantage can work for your clients, leave a message at the number below and a representative will get back to you within 24 hours. I-800-2I This brochure is provided for your information only and is not for distribution to commercial (non-medicare) enrollees or Medicare beneficiaries.

3 OXFORD MEDICARE ADVANTAGE GROUP PLAN MEDICAL RIDERS $5 per primary care physician or specialist visit per primary care physician and $15 per specialist visit $15 per primary care physician or specialist visit $10 per primary care physician or specialist visit Reduce emergency room (ER) copayment from $50 to $25 Reduce emergency room (ER) copayment from $50 to $30 Reduce emergency room (ER) copayment from $50 to $35 $10 mental health copayment OXFORD MEDICARE ADVANTAGE GROUP PLAN PRESCRIPTION RIDERS RIDER 1* RIDER 6* $5 copayment for each generic drug $7 copayment for each generic drug $10 copayment for each preferred brand name drug $15 copayment for each brand name drug Unlimited generic and brand name drugs Unlimited generic and $1,500 annual brand name drug maximum RIDER 2* $7 copayment for each generic drug RIDER 7* $20 copayment for each preferred brand name drug $10 copayment for each generic drug $50 copayment for each non-preferred brand $20 copayment for each preferred brand name drug name drug $35 copayment for each non-preferred brand Unlimited generic and brand name drugs name drug Unlimited generic and $2,500 annual brand RIDER 3* name drug maximum $7 copayment for each generic drug $20 copayment for each preferred brand name drug RIDER 8* $50 copayment for each non-preferred brand $15 copayment for each generic drug name drug $25 copayment for each preferred brand name drug Unlimited generic and $2,500 annual brand name $50 copayment for each non-preferred drug maximum brand name drug Unlimited generic and brand name drugs RIDER 4* $10 copayment for each generic drug RIDER 9* $20 copayment for each preferred brand $15 copayment for each generic drug name drug $25 copayment for each preferred brand name drug $35 copayment for each non-preferred brand $50 copayment for each non-preferred brand name drug name drug Unlimited generic and $2,500 annual brand Unlimited generic and brand name drugs name drug maximum RIDER 5* $7 copayment for each generic drug $15 copayment for each preferred brand name drug Unlimited generic and brand name drugs Oxford Medicare Advantage benefits are provided by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc., HMOs operating under Medicare Advantage contracts Oxford Health Plans, LLC. $15 mental health copayment 100% inpatient hospitalization coverage, as medically necessary (no copayments or deductibles) Enhanced dental benefit (CT Only) The Oxford Medicare Advantage group plan riders listed below offer a unique way to costumize your specific plan. RIDER 10* $7 copayment for each generic drug $15 copayment for each preferred brand name drug $25 copayment for each non-preferred brand name drug Unlimited generic and $1,500 annual brand name drug maximum RIDER 11* $7 copayment for each generic drug $15 copayment for each preferred brand name drug $25 copayment for each non-preferred brand name drug Unlimited generic and brand name drugs RIDER 12* $5 copayment for each generic drug $10 copayment for each preferred brand name drug $20 copayment for each non-preferred brand name drug Unlimited generic and brand name drugs RIDER 13* Standard Prescription Coverage** ** OMA offers a Standard Prescription Coverage Rider within each service area. Call for details.

4 UNITEDHEALTHCARE For over 20 years, United Healthcare and its affiliates have offered Medicare plans to serve healthcare coverage needs of older adults and certain people with disabilities. UNITED HEALTHCARE INDIVIDUAL PLANS The comparison charts in this packet provide an overview of the individual plan being offered in the Bronx, Kings, New York, Queens, and Richmond counties. United HealthCare also offers a Passport Option. This option allows a member to live up to nine months in one of the UHC s national service areas and access those physicians on an in-network basis. Prior to departing, UHC asks that the Member contact their Personal Service Specialist to inform them where they are going and for how long. UNITED HEALTHCARE GROUP PLANS United HealthCare offers both an HMO and POS national option (within the passport counties). premium and premium plans are available in these areas. UHC also offers Medicare Group Plans to groups who have 50 eligibles within a service area. The minimum employer contribution is 75%. UNITED HEALTHCARE PHYSICIAN NETWORK United HealthCare individual and group plan Members have access to the entire United HealthCare provider network within these following states and counties: Alabama: Birmingham (Bibb, Blount, Chilton, Elmore, Jefferson, Lowndes, Macon, Montgomery, Russell, Saint Clair and Shelby); WalkerMobile (Baldwin and Mobile) Arizona: Pima and Santa Cruz Florida: Tampa (Charlotte, Hernando, Hillsborough, Lee, Manatee, Pasco, Pinellas, Polk and Sarasota); South Florida (Broward, Miami-Dade and Palm Beach) Illinois: Madison, Monroe, St. Clair Madison, Monroe and St. Clair Iowa: Crawford, Page, Pottawattamie and Shelby Missouri: St. Louis (Crawford, Franklin, Jefferson, Lincoln, St. Charles, St. Louis County, St. Louis City and Warren); Springfield (Barry, Christian, Crawford, Dallas, Douglas, Greene, Laclede, Lawrence, Lincoln, McDonald, Polk, Texas, Webster and Wright) Nebraska: Burt, Cass, Douglas, Otoe, Sarpy and Washington New York: New York City (Bronx, Kings, New York, Queens, Richmond); Syracuse (Cayuga, Oneida, Onondaga); Buffalo (Erie); Albany (Albany, Rensselaer, and Schenectady) Rhode Island: Bristol, Kent, Newport, Providence and Washington rth Carolina: Alamance, Caswell, Chatham, Davidson, Davie, Durham, Forsyth, Guilford, Mecklenburg, Orange, Person, Randolph, Rockingham, Rowan, Stokes, Surry, Wake, Wilkes and Yadkin Ohio: Butler, Clark, Cuyahoga, Franklin, Hamilton, Madison, Mahoning, Montgomery, Stark, Summit, Trumbull and Warren Tennessee: Davidson, De Kalb, Hickman and Rutherford Utah: Box Elder, Davis, Morgan, Salt Lake, Summit, Wasatch and Weber Wisconsin: Milwaukee, Ozaukee, Washington and Waukesha For more information about how United HealthCare can work for your clients, leave a message at the number below and a representative will get back to you within 24 hours. I-800-2I This brochure is provided for your information only and is not for distribution to commercial (non-medicare) enrollees or Medicare beneficiaries.

5 2005 OXFORD MEDICARE ADVANTAGE PLAN COMPARISON (New York: Manhattan, Queens and Richmond Counties) Benefit Original Medicare Oxford Medicare Oxford Medicare Advantage Signature SM Advantage Balance SM Monthly Plan Premium Referral Required Primary Care Physician (PCP) or Specialist Visits Routine Physical Exam Outpatient Prescription Drug Coverage Generic Prescription Drug Cost Preferred Brand Prescription Drug Cost n-preferred Brand Prescription Drug Cost Deductible Inpatient Hospital Care Outpatient Hospital Care Emergency and Urgent Care Coverage $78.20 Medicare Part B premium Covers 80% after $110 deductible is met one time exam within 6 months of Part B coverage In general, there is no coverage for prescription drugs $110 per calendar year Days 1-60: an initial deductible of $912 Days 61-90: $228 deductible per day Days : $456 each lifetime reserve day 4 Covers 80% after $110 deductible is met Covered in the United States and U.S. territories additional monthly plan premium 1 $15 per visit to PCP $25 per visit to specialist for PCP and OB/GYN routine physical exams There is no annual limit for generic drugs and $1,100 toward preferred and non-preferred brand name drugs $15 The greater of $25 or 50% of the total cost 2 of the covered drug The greater of $50 or 50% of the total cost 2 of the covered drug $80 inpatient facility copayment per day (not to exceed $640 per hospital stay); $150 inpatient physician surgery copayment $250 ambulatory facility copayment; $100 ambulatory surgery physician copayment Covered worldwide additional monthly plan premium 1 $5 per visit to PCP $10 per visit to specialist for PCP and OB/GYN routine physical exams There is no annual limit for generic drugs and $1,200 toward preferred and non-preferred brand name drugs $15 The greater of $25 or 50% of the total cost 2 of the covered drug The greater of $50 or 50% of the total cost 2 of the covered drug $1,500 per calendar year after Oxford has paid $500 3 (in-network only) 3 (subject to the deductible) 3 (subject to the deductible) Covered worldwide

6 Benefit Original Medicare Oxford Medicare Oxford Medicare Advantage Signature SM Advantage Balance SM Vision Care Hearing Care Dental Care Fitness Benefit Podiatry Care Nutrition Benefit Radiology Services Ambulance Services coverage for routine exams, corrective lenses or eyeglasses; eyeglasses are covered following cataract surgery Covers exams to determine treatment of hearing deficit or other medical problem coverage for routine care coverage coverage for routine care coverage Covers 80% after $110 deductible is met Covers 80% after $110 deductible is met for one eye exam once every 12 months and for one pair of eyeglasses once every 24 months at Davis Vision centers or up to a $50 reimbursement for an eye exam once every 12 months and up to a $70 reimbursement for eyeglasses once every 24 months from a provider of your choice for one hearing exam once every 12 months and up to a $500 credit toward the purchase of the first hearing aid and up to a $500 credit toward the purchase of the second hearing aid once every 36 months at a HearX center or up to a $300 reimbursement for a hearing aid from a supplier of your choice once every 36 months for preventive and diagnostic dental care, including a dental cleaning every six months for fitness classes and gym memberships at participating SilverSneakers facilities for one routine visit per quarter for one routine visit per quarter for nutrition assessment and $25 per for nutrition assessment and $10 per visit visit for two nutrition intervention visits for two nutrition intervention visits 20% coinsurance 20% coinsurance 3 (subject to the deductible) 1 You must continue to pay your Medicare Part B premium. 2 The cost of covered drugs will reflect Oxford's discounted rates, plus a prescription dispensing fee, minus an average per drug forecast of the pharmacy rebates Oxford expects to receive for formulary drugs. 3 Coverage is based on the calendar year. The $1,500 deductible is prorated. If the effective date of membership is after June 30, the deductible is $750 after Oxford has paid $250. The deductible applies to certain services such as inpatient hospital care, outpatient surgery, etc. Copayments do not apply to services that are subject to the deductible. Once the deductible is met, Oxford pays 100% for services subject to the deductible. 4 Lifetime reserve days can only be used once. Members must receive routine care from plan providers, be entitled to Medicare Part A and Part B, and continue to pay Medicare premiums. Oxford Health Plans (NY), Inc. is a licensed HMO operating under Medicare Advantage contracts Oxford Health Plans, LLC.

7 2005 OXFORD MEDICARE ADVANTAGE PLAN COMPARISON (New York: Westchester County) Benefit Original Medicare Oxford Medicare Oxford Medicare Advantage Signature SM Advantage Balance SM Monthly Plan Premium $78.20 Medicare Part B premium additional monthly plan premium 1 additional monthly plan premium 1 Referral Required Primary Care Physician (PCP) or Specialist Visits Covers 80% after $110 deductible is met $15 per visit to PCP $25 per visit to specialist $10 per visit to PCP $20 per visit to specialist Routine Physical Exam one time exam within six months of Part B coverage for PCP and OB/GYN routine physical exams for PCP and OB/GYN routine physical exams Outpatient Prescription Drug Coverage In general, there is no coverage for prescription drugs There is no annual limit for generic drugs There is no annual limit for generic drugs and $600 toward preferred and non-preferred brand name drugs Generic Prescription Drug Cost $15 $15 Preferred Brand Prescription Drug Cost The greater of $25 or 50% of the total cost 2 of the covered drug n-preferred Brand Prescription Drug Cost The greater of $50 or 50% of the total cost 2 of the covered drug Deductible $110 per calendar year $2,800 per calendar year after Oxford has paid $500 3 (in-network only) Inpatient Hospital Care Days 1-60: an initial deductible of $912 Days 61-90: $228 deductible per day Days : $456 each lifetime reserve day 4 $150 inpatient facility copayment per day (not to exceed $1,500 per hospital stay); $150 inpatient physician surgery copayment 3 (subject to the deductible) Outpatient Hospital Care Covers 80% after $110 deductible is met $250 ambulatory facility copayment; $100 ambulatory surgery physician copayment 3 (subject to the deductible) Emergency and Urgent Care Coverage Covered in the United States and U.S. territories Covered worldwide Covered worldwide

8 Benefit Original Medicare Oxford Medicare Oxford Medicare Advantage Signature SM Advantage Balance SM Vision Care Hearing Care Dental Care Fitness Benefit Podiatry Care Nutrition Benefit Radiology Services Ambulance Services coverage for routine exams, corrective lenses or eyeglasses; eyeglasses are covered following cataract surgery Covers exams to determine treatment of hearing deficit or other medical problem coverage for routine care coverage coverage for routine care coverage Covers 80% after $110 deductible is met Covers 80% after $110 deductible is met for one eye exam once every 12 months and for one pair of eyeglasses once every 24 months at Davis Vision centers or up to a $50 reimbursement for an eye exam once every 12 months and up to a $70 reimbursement for eyeglasses every 24 months from a provider of your choice for one hearing exam once every 12 months and up to a $500 credit toward the purchase of the first hearing aid and up to a $500 credit toward the purchase of the second hearing aid once every 36 months at a HearX center or up to a $300 reimbursement for a hearing aid from a supplier of your choice once every 36 months for preventive and diagnostic dental care, including a dental cleaning every six months for fitness classes and gym memberships at participating SilverSneakers facilities for one routine visit per quarter for one routine visit per quarter for nutrition assessment and $25 per visit for two nutrition intervention visits for nutrition assessment and $20 per visit for two nutrition intervention visits 3 (subject to the deductible) 1 You must continue to pay your Medicare Part B premium. 2 The cost of covered drugs will reflect Oxford's discounted rates, plus a prescription dispensing fee, minus an average per drug forecast of the pharmacy rebates Oxford expects to receive for formulary drugs. 3 Coverage is based on the calendar year. The $2,800 deductible is prorated. If the effective date of membership is after June 30, the deductible is $1,400 after Oxford has paid $250. The deductible applies to certain services, such as inpatient hospital care, outpatient surgery, etc. Copayments do not apply to services that are subject to the deductible. Once the deductible is met, Oxford pays 100% for services subject to the deductible. 4 Lifetime reserve days can only be used once. Members must receive routine care from plan providers, be entitled to Medicare Part A and Part B, and continue to pay Medicare premiums. Oxford Health Plans (NY), Inc. is a licensed HMO operating under Medicare Advantage contracts Oxford Health Plans, LLC.

9 2005 OXFORD MEDICARE ADVANTAGE MOSAIC SM PLAN (New York: Bronx, Kings, New York, Queens and Richmond Counties) This plan is designed to meet the language needs of Chinese, Korean and Hispanic beneficiaries. We have created a focused network that includes physicians who are fluent in Chinese, Korean and Spanish. This network will include the same hospitals as our existing Oxford Medicare Advantage network. Benefit Original Medicare Oxford Medicare Advantage Mosaic SM Monthly Plan Premium 1 Referral Required Primary Care Physician (PCP) or Specialist Visits Generic Drug Cost Inpatient Hospital Care Inpatient Hospital Surgery Copayment Ambulatory Surgery Facility Copayment Ambulatory Surgery Physician Copayment Radiology Services $78.20 Medicare Part B premium Day 1-60: an initial deductible of $912 Day 61-90: $228 deductible per day Day : $456 each lifetime reserve day 2 per visit to PCP and OB/GYN $5 per visit to specialist $15; There is no annual limit for generic drugs Ambulance Services

10 Benefit Original Medicare Oxford Medicare Advantage Mosaic SM Vision Care Hearing Care Podiatry Care Dental Care Nutrition Benefit Fitness Benefit coverage for routine exams, corrective lenses or eyeglasses; eyeglasses are covered following cataract surgery Covers exams to determine treatment of hearing deficit or other medical problems coverage for routine care coverage for routine care coverage coverage for one eye exam every 12 months and for one pair of eyeglasses every 24 months at Davis Vision centers or up to a $50 reimbursement for an eye exam every 12 months and up to a $70 reimbursement for eyeglasses every 24 months from a provider of your choice for one hearing exam every 12 months and up to a $500 credit toward the purchase of the first hearing aid and up to a $500 credit toward a second hearing aid once every 36 months at Hearx center or up to a $300 reimbursement for a hearing aid from a supplier of your choice once every 36 months for one routine visit per quarter preventive and diagnostic dental care, including a dental cleaning every six months for nutrition assessment and $5 per visit for two nutrition intervention visits for fitness classes and gym memberships at participating SilverSneakers facilities Although the Oxford Medicare Advantage Mosaic SM plan does not offer brand name prescription drug coverage, Members may be eligible for Elderly Pharmaceutical Insurance Coverage (EPIC), the NY state-assisted medication program. Eligibility is based on annual income and age (65 or older). For more information, contact EPIC toll-free at , or write to P.O. Box 15018, Albany, NY You must continue to pay your Medicare Part B premium. 2 Lifetime reserve days can only be used once. Members must receive routine care from plan providers, be entitled to Medicare Part A and B, and continue to pay Medicare premiums. Oxford Health Plans (NY), Inc., is a licensed HMO operating under a Medicare Advantage contract Oxford Health Plans, LLC.

11 2005 OXFORD MEDICARE ADVANTAGE PLAN COMPARISON (New York: Orange and Rockland Counties and New Jersey: Bergen, Essex, Ocean and Union Counties) Benefit Original Medicare Oxford Medicare Oxford Medicare Advantage Signature SM Advantage Balance SM Monthly Plan Premium $78.20 Medicare Part B premium additional monthly plan premium 1 additional monthly plan premium 1 Referral Required Primary Care Physician (PCP) or Specialist Visits Covers 80% after $110 deductible is met $10 per visit to PCP $20 per visit to specialist $10 per visit to PCP $20 per visit to specialist Routine Physical Exam one time exam within 6 months of Part B coverage for PCP and OB/GYN routine physical exams for PCP and OB/GYN routine physical exams Outpatient Prescription Drug Coverage In general, there is no coverage for prescription drugs There is no annual limit for generic drugs There is no annual limit for generic drugs and $600 toward preferred and non-preferred brand name drugs Generic Prescription Drug Cost $15 $15 Preferred Brand Prescription Drug Cost The greater of $25 or 50% of the total cost 2 of the covered drug n-preferred Brand Prescription Drug Cost The greater of $50 or 50% of the total cost 2 of the covered drug Deductible $110 per calendar year $2,000 per calendar year after Oxford has paid $500 3 (in-network only) Inpatient Hospital Care Days 1-60: an initial deductible of $912 Days 61-90: $228 deductible per day Days : $456 each lifetime reserve day 4 $80 inpatient facility copayment per day (not to exceed $800 per hospital stay); inpatient physician surgery copayment 3 (subject to the deductible) Outpatient Hospital Care Covers 80% after $110 deductible is met $100 ambulatory facility copayment; ambulatory surgery physician copayment 3 (subject to the deductible) Emergency and Urgent Care Coverage Covered in the United States and U.S. territories Covered worldwide Covered worldwide

12 Benefit Original Medicare Oxford Medicare Oxford Medicare Advantage Signature SM Advantage Balance SM Vision Care Hearing Care Dental Care Fitness Benefit Nutrition Benefit Podiatry Care Radiology Services Ambulance Services coverage for routine exams, corrective lenses or eyeglasses; eyeglasses are covered following cataract surgery Covers exams to determine treatment of hearing deficit or other medical problem coverage for routine care coverage coverage coverage for routine care Covers 80% after $110 deductible is met Covers 80% after $110 deductible is met for one eye exam once every 12 months and for one pair of eyeglasses once every 24 months at Davis Vision centers or up to a $50 reimbursement for an eye exam once every 12 months and up to a $70 reimbursement for eyeglasses once every 24 months from a provider of your choice for one hearing exam once every 12 months and up to a $500 credit toward the purchase of the first hearing aid and up to a $500 credit toward the purchase of the second hearing aid once every 36 months at a HearX center or up to a $300 reimbursement for a hearing aid from a supplier of your choice once every 36 months for preventive and diagnostic dental care, including a dental cleaning every six months for fitness classes and gym memberships at participating SilverSneakers facilities for nutrition assessment and $20 per visit for two nutrition intervention visits for one routine visit per quarter for one routine visit per quarter 3 (subject to the deductible) 1 You must continue to pay your Medicare Part B premium. 2 The cost of covered drugs will reflect Oxford's discounted rates, plus a prescription dispensing fee, minus an average per drug forecast of the pharmacy rebates Oxford expects to receive for formulary drugs. 3 Coverage is based on the calendar year. The $2,000 deductible is prorated. If the effective date of membership is after June 30, the deductible is $1,000 after Oxford has paid $250. The deductible applies to certain services such as inpatient hospital care, outpatient surgery, etc. Copayments do not apply to services that are subject to the deductible. Once the deductible is met, Oxford pays 100% for services subject to the deductible. 4 Lifetime reserve days can only be used once. Members must receive routine care from plan providers, be entitled to Medicare Part A and Part B, and continue to pay Medicare premiums. Oxford Health Plans (NJ), Inc. and Oxford Health Plans (NY), Inc. are licensed HMOs operating under Medicare Advantage contracts Oxford Health Plans, LLC.

13 2005 OXFORD MEDICARE ADVANTAGE PLAN (New Jersey: Hudson County) Benefit Original Medicare Oxford Medicare Advantage Monthly Plan Premium Referral required for specialist visits Primary Care Physician (PCP) or Specialist Visits Routine Physical Exam Outpatient Prescription Drug Coverage Generic Prescription Drug Cost Preferred brand name drug cost n-preferred brand name drug cost Inpatient Hospital Care Inpatient hospital surgery copayment Ambulatory surgery facility copayment Ambulatory surgery physician copayment Emergency and Urgent Care Coverage $78.20 Medicare Part B premium one time exam within 6 months of Part B coverage In general, there is no coverage for prescription drugs You pay 100% for most prescription drugs You pay 100% for most prescription drugs Days 1-60: an initial deductible of $912 Days 61-90: $228 deductible per day Days : $456 each lifetime reserve day 3 Covered in the United States and U.S. territories additional monthly plan premium 1 $10 per visit to PCP $25 per visit to specialist for PCP and OB/GYN routine physical exams There is no annual limit for generic drugs and $500 toward preferred and non-preferred brand name drugs $15 The greater of $25 or 50% of the total cost 2 of the covered drug The greater of $50 or 50% of the total cost 2 of the covered drug $80 per day; not to exceed $640 per hospital stay $150 $250 $100 Covered worldwide

14 Benefit Original Medicare Oxford Medicare Advantage Vision Care Hearing Care Podiatry Care Dental Care Nutrition Benefit Fitness Benefit Radiology Services Ambulance Services coverage for routine exams, corrective lenses or eyeglasses; eyeglasses are covered following cataract surgery Covers exam to determine treatment of hearing deficit or other medical problem coverage for routine care coverage for routine care coverage coverage for one eye exam every 12 months and for one set of glasses every 24 months at Davis Vision centers or up to a $50 reimbursement for an eye exam every 12 months and up to a $70 reimbursement for eyeglasses every 24 months from a provider of your choice for one hearing exam every 12 months and up to a $500 credit toward the purchase of the first hearing aid and up to a $500 credit toward the second hearing aid once every 36 months at a HearX center or up to a $300 reimbursement for a hearing aid from a supplier of your choice every 36 months for one routine visit per quarter for preventive and diagnostic dental care, including a dental cleaning every six months for nutrition assessment and $25 per visit for two nutrition intervention visits for fitness classes and gym memberships at participating SilverSneakers facilities 20% coinsurance 20% coinsurance 1 You must continue to pay your Medicare Part B premium. 2 The cost of covered drugs will reflect Oxford s discounted rates, plus a prescription dispensing fee, minus an average per drug forecast of the pharmacy rebates Oxford expects to receive for formulary drugs. 3 Lifetime reserve days can only be used once. Members must receive routine care from plan providers, be entitled to Medicare Part A and Part B, and continue to pay Medicare premiums. Oxford Health Plans (NJ), Inc. is a licensed HMO operating under a Medicare Advantage contract Oxford Health Plans, LLC.

15 2005 OXFORD MEDICARE ADVANTAGE BALANCE SM PLAN (New Jersey: Mercer, Middlesex, Monmouth and Passaic Counties) Benefit Original Medicare Oxford Medicare Advantage Monthly Plan Premium Referral Required for Specialist Visits Primary Care Physician (PCP) or Specialist Visits Routine Physical Exam Outpatient Prescription Drug Coverage Generic Prescription Drug Copayment Deductible Inpatient Hospital Care Outpatient Hospital Care Emergency and Urgent Care Coverage $78.20 Medicare Part B premium Covers 80% after $110 deductible is met one time exam within 6 months of Part B coverage In general, there is no coverage for prescription drugs $110 per calendar year Days 1-60: an initial deductible of $912 Days 61-90: $228 deductible per day Days : $456 each lifetime reserve day 3 Covers 80% after $110 deductible is met Covered in the United States and U.S. territories additional monthly plan premium 1 $10 per visit to PCP $20 per visit to specialist for PCP and OB/GYN routine physical exams There is no annual limit for generic drugs $15 $2,000 per calendar year after Oxford has paid $500 2 (in-network only) 2 (subject to the deductible) 2 (subject to the deductible) Covered worldwide Balance SM

16 Benefit Original Medicare Oxford Medicare Advantage Balance SM Vision Care Hearing Care Podiatry Care Dental Care Nutrition Benefit Fitness Benefit Radiology Services Ambulance Services coverage for routine exams, corrective lenses or eyeglasses; eyeglasses are covered following cataract surgery Covers exam to determine treatment of hearing deficit or other medical problem coverage for routine care coverage for routine care coverage coverage for one eye exam every 12 months and for one set of glasses every 24 months at Davis Vision centers or up to a $50 reimbursement for an eye exam every 12 months and up to a $70 reimbursement for eyeglasses every 24 months from a provider of your choice for one hearing exam every 12 months and up to a $500 credit toward the purchase of the first hearing aid and up to a $500 credit toward a second hearing aid once every 36 months at a HearX center or up to a $300 reimbursement for a hearing aid from a supplier of your choice every 36 months for one routine visit per quarter for preventive and diagnostic dental care, including a dental cleaning every six months for nutrition assessment and $20 per visit for two nutrition intervention visits for fitness classes and gym memberships at participating SilverSneakers facilities 2 (subject to the deductible) 1 You must continue to pay your Medicare Part B premium. 2 Coverage is based on the calendar year. The $2,000 deductible is prorated. If the effective date of membership is after June 30, the deductible is $1,000 after Oxford has paid $250. The deductible applies to certain services such as inpatient hospital care, outpatient surgery, etc. Copayments do not apply to services subject to the deductible. Once the deductible is met, Oxford pays 100% for services that are subject to the deductible. 3 Lifetime reserve days can only be used once. Members must receive routine care from plan providers, be entitled to Medicare Part A and Part B, and continue to pay Medicare premiums. Oxford Health Plans (NJ), Inc. is a licensed HMO operating under a Medicare Advantage contract Oxford Health Plans, LLC.

17 2005 MEDICARE COMPLETE CHOICE PLAN COMPARISON (Bronx, Kings, New York, Queens, Richmond) The Medicare Complete Choice plan provides Medicare beneficiaries with an affordable alternative to Original Medicare. For added flexibility, Medicare Complete Choice combines in-network and out-of-network coverage and you ll receive benefits you can t get with Original Medicare alone, such as prescription drug coverage. The tables below and on the reverse highlight the differences between our UnitedHealthcare plan and Original Medicare. Benefit Original Medicare Medicare Complete Choice Medicare Complete Choice (when using network providers) (when using out-of network providers) Monthly Plan Premium Referral Required Primary Care Physician (PCP) or Specialist Visits Routine Physical Exam Outpatient Prescription Drug Coverage Generic Prescription Drug Cost Inpatient Skilled Nursing Facility Services Diagnostic Tests, X-ray and Lab Services Inpatient Hospital Care Outpatient Rehabilitation Services $78.20 Medicare Part B premium Covers 80% after $110 deductible is met one time exam within six months of Part B coverage In general, there is no coverage for prescription drugs You pay for each benefit period, following at least a 3-day covered hospital stay: Days 1-20: for each day, Days : $114 for each day. There is a limit of 100 days for each benefit period. Covers 80% after $110 deductible is met Days 1-60: an initial deductible of $912 Days 61-90: $228 deductible per day Days : $456 each lifetime reserve day Covers 80% after $110 deductible is met $26.00 $5 per visit to PCP $20 per visit to specialist $5 for PCP and OB/GYN routine physical exams There is no annual limit for generic drugs $9.00 Days 1-31: $75 per day $10 for each Medicare-covered clinical lab service, $10 for standard flat film X-rays and 20% coinsurance for other radiological services Days 1-15: $160 inpatient facility copayment 20% coinsurance for the cost of each Medicare-covered Occupational, Physical, or Speech Therapy visit $ % coinsurance 20% coinsurance There is no annual limit for generic drugs 20% coinsurance 20% coinsurance 20% coinsurance for each Medicarecovered clinical lab service, 20% co-insurance for standard flat film X-rays and 20% Co-insurance for other radiological services 20% coinsurance 20% coinsurance for the cost of each Medicare-covered Occupational, Physical, or Speech Therapy visit

18 Benefit Original Medicare Medicare Complete Choice Medicare Complete Choice (when using network providers) (when using out-of network providers) Outpatient Surgery Vision Care Hearing Care Covers 80% after $110 deductible is met coverage for routine exams, corrective lenses or eyeglasses; eyeglasses are covered following cataract surgery Covers exam to determine treatment of hearing deficit or other medical problem 20% of coinsurance for each Medicarecovered visit to an ambulatory surgical center or outpatient hospital facility $20 for one diagnostic eye exam every 12 months and $20 for one routine eye exam every 12 months; One pair of eyeglasses after cataract surgery $20 for one hearing exam every 12 months and $20 for one routine hearing exam every 12 months 20% coinsurance for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility 20% of coinsurance 20% coinsurance Annual Out-of- Pocket Maximum t Applicable $2,400 Unlimited Ambulance Services Covers 80% after $110 deductible is met $100 per one way trip for Medicare-covered services $100 per one way trip for Medicare-covered services If you have any questions regarding the Medicare Complete Choice Plan, call (TDD: ), Monday through Friday, between 8:00 AM and 5:30 PM or visit us online at 1 You must continue to pay your Medicare Part B premium 2 Annual out-of-pocket maximum applies to these services. Other services are included in the out-of-pocket maximum. 3 There is no out-of-pocket maximum for services obtained out-of-network. 4 Enrollees will be reimbursed for prescription drug products obtained out-of-network at our in-network contracted rate less any applicable copayment amount. Out-of-network prescription drug products will count toward the annual drug maximum. To be eligible for this plan, enrollees must be entitled to Part A and enrolled in Part B of Medicare. This comparison chart does not list every service that we cover or list every limitation or exclusion. Please refer to the appropriate Summary of Benefits for further benefit information. NY-xx-xxx 8137

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