E Fulfillment

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for all seasons

www.oxfordhealth.com
MS-05-1293 In-Area Welcome Letter (1.11)

Dear Oxford Member,

Welcome, and thank you for selecting Oxford Health Plans.

At Oxford, your satisfaction is important to us, and we strive to help make your healthcare experience a
positive one. As an Oxford Member, you have access to a series of programs and resources to help you
along your road to health:

A robust network of hospitals and providers from a local health plan with over 20 years of
experience. If your employers plan offers out-of-area coverage, you also have in-network
national access outside of Oxfords tri-state service area through the UnitedHealthcare Choice
Plus network.
Our Healthy Bonus
1
program, which consists of special offers and discounts that help you stay
healthy and manage special conditions. Members can save on services such as weight loss
programs, fitness equipment and publications.
Our web site, www.oxfordhealth.com, which allows you to conduct business (e.g., request an ID
card, update or correct any personal information, etc.) and access health information at your
convenience.
Healthcare guidance 24 hours a day, seven days a week, from Oxfords registered nurses through
Oxford On-Call

Healthy Mind Healthy Body
magazine, your source for health information on prevention,

nutrition, and exercise, as well as important benefit and coverage information.

The following information is enclosed: your new Summary of Benefits, Certificate of Coverage and other
important plan information. If you have questions about your coverage, or want to learn more about
Oxford's programs and resources, please log on to www.oxfordhealth.com or call Customer Service at the
number on your Oxford ID card.

Wishing you the best of health,

Oxford Health Plans

1
Healthy Bonus offers are not insured benefits and are in addition to, and separate from, your benefit coverage
through Oxford Health Plans. These arrangements have been made for the benefit of Members, and do not represent
an endorsement or guarantee on the part of Oxford. Offers may change from time to time and without notice and are
applicable to the items referenced only. Offers are subject to the terms and conditions imposed by the vendor.
Oxford Health Plans cannot assume any responsibility for the products or services provided by vendors or the failure
of vendors referenced to make available discounts negotiated with Oxford; however, any failure to receive offers
should be reported to Oxford Customer Service by calling the number on your Member ID card.
OXFORD HEALTH INSURANCE, INC.
COVERED SERVICES
SUMMARY OF BENEFITS
Sprout Creek Farm
EXCLUSIVE PLAN METRO LIBERTY NETWORK
All visits for treatment of illness and injury are Covered subject to $25 Copayment per visit. Some procedures
Inpatient Hospital Visit
Diabetes Education and Self-
Management
Diabetic Supplies
Specialty Care
Physician Office and Home
Visits
Inpatient Hospital Visit
Obstetrical Services (Including
prenatal and postnatal)
Elective Termination of Pregnancy
Physician Office and Home Visits:
No Charge for Preventive Care (both child and adult)
Well-woman examinations, Pap tests, and age appropriate mammograms are Covered at No Charge.
Covered subject to $25 Copayment per visit
require Precertification. Please see your Certificate.
Covered at a Copayment of $25 for a 31-day supply of each item.
Covered subject to $50 Copayment per visit. Some procedures
Covered $25 Copayment per initial visit.
No Charge for Physicians services.
Covered subject to Deductible and 10% Coinsurance
Precertification is required for the purchase of an insulin pump.
require Precertification.
Certificate.
Some procedures require Precertification.
Certificate.
Primary Care Visits require a $25
Copayment
Specialty Care Visits require a $50
Copayment
Pediatric Preventive Dental (for children
under age 12)
No Charge
Covered subject to Deductible and 10% Coinsurance.
Please see your
Please see your
Page 1 of 9 OHINY EPO SB S 112 SC36889*CSP03 Effective: January 01, 2013 NYSM_EPO_BS_11.01.12_v.1
COVERED SERVICES
Treatment of Infertility (Basic
and Comprehensive Services)
Covered subject to $50 per visit. Allergy Testing and Treatment
Short-Term Rehabilitation Services (Physical, Speech
and Occupational)
Outpatient
Inpatient
Oral Surgery
Inpatient
Outpatient
Office Visit
Advanced Services are not Covered.
Covered subject to $50 Copayment per visit.
Some procedures require Precertification. Please see your Certificate.
Precertification is required
Covered subject to $50 Copayment per office visit.
Covered subject to Deductible and 10% Coinsurance per outpatient visit.
Covered subject to Deductible and 10% Coinsurance per inpatient visit.
Covered $50 Copayment per visit.
Precertification is required.
Laboratory Procedures
Radiology and X-ray
Examinations
Diagnostic Mammography
No Charge
50% Copayment to a maximum Member payment of $100
No Charge
for PET scans, MRI, Nuclear Medicine, CAT Scans Precertification is required
COVERED SERVICES
Prosthetic Devices
Durable Medical Equipment
Medical Supplies
Precertification is required before purchase.
Related surgery is Covered subject to Deductible and 10% Coinsurance.
Internal prosthetic devices are Covered at No Charge.
External prosthetic devices are Covered at No Charge.
Precertification is required on items that cost $500 or more.
Transplants Transplants performed at Our approved facilities
Home Health Care
Covered subject to 10% Coinsurance.
Chiropractic Services Covered at $50 Copayment per visit.
Second Opinions At your request:
At Our request, No Charge.
Covered at $50 Copayment per visit.
Hospital and Other Facility Based Services
Inpatient Hospital Services Covered subject to Deductible and 10% Coinsurance.
Transplants performed at other Network Facilities are not Covered.
Hearing Aids
Precertification is required on items that cost $500 or more.
Covered subject to Deductible and 10% Coinsurance. - Coverage is
limited to a maximum payment
by Us of $1,500. Benefits are
limited to a single purchase
(including repair/replacement)
every 3 Years Calendar Years.
are Covered subject to Deductible and 10% Coinsurance.
COVERED SERVICES
Hospice Services
Alcohol and Substance Abuse Services
Inpatient
Outpatient
Home Health Care
Skilled Nursing Facility
Covered subject to 10% Coinsurance.
(Waived if a Member is transferred from a Hospital to a Skilled Nursing Facility).
Outpatient Alcohol and
Substance Abuse Rehabilitation
Inpatient Substance Abuse
Rehabilitation and
Detoxification
Precertification Required.
Outpatient Hospital Services
and Ambulatory Surgical
Center Services
Services
(Waived if a Member is transferred from a Hospital to a Skilled Nursing Facility).
Hospital and Other Facility Based
Services (contd)
Covered subject to $50 Copayment.
COVERED SERVICES
Emergency Room Services
Medical Emergency and Urgent Care
Services
Urgent Care Facility Services
Ambulance Services
When proper notice is given, the services of Network and Non-Network
Providers are Covered subject to $50 Copayment per visit.
Covered subject to $200 Copayment per visit (Waived if a Member becomes confined in a Hospital).
(Waived if a Member becomes confined in a Hospital).
Covered at No Charge.
Mental Health Services
Outpatient Mental Health
Services and Partial
Hospitalization Visits
Inpatient Mental Health
Services
Covered subject to Deductible and 10% Coinsurance
Precertification required
Office Visits - Covered at $50 Copayment per visit.
Outpatient - Covered $50 Copayment per outpatient visit.
COVERED SERVICES
Diabetic Supplies Diabetic supplies will only be supplied in amounts consistent with the Members treatment plan as
developed by the Members Physician. Only basic models of blood glucose monitors are Covered unless
the Member has special needs relating to poor vision or blindness.
Outpatient Prescription Drugs Subject to a separate Deductible of $100 per Member per Contract Year. The Deductible is
waived for Tier 1 Drugs.
Tier 1: $15 per each Prescription and refill, per 31-day supply.
Mail Order:
When filled at Our Network Mail Order Pharmacy, You will be charged 2.5 Copayments for a
90-day supply.
Please Note:
Certain drugs require Precertification.
Vision Care We will reimburse up to $50 every 12 months for a vision examination. We will reimburse up to $70 every 24
months for one set of appliances.
For certain medications, We will Cover a 31-day supply with two refills through the retail
pharmacy. Once it is determined that the medication is appropriate to treat your condition, you will be required
to obtain the medication through Our mail order supplier.
Supplemental Coverage
MAXIMUMS AND LIMITATIONS
Elective Termination of
Pregnancy
We Cover one procedure per Member, per Calendar Year. We pay a maximum benefit of $350 per procedure.
MAXIMUMS AND LIMITATIONS (contd)
Outpatient Alcoholism and
Inpatient Alcohol and
Detoxification
Short Term Rehabilitative Therapy
Services (physical, speech and
occupational therapy)
Inpatient Rehabilitation
Outpatient
Rehabilitation
and Medical Supplies
Transplants
Home Health Services
Exercise Facility
Reimbursement
Services
Hospice Services
Bereavement
Counseling for the
Members family
One consecutive 60-day period per condition, per lifetime
60 visits per condition, per lifetime
We will pay a maximum benefit of $1,500 per Member per calendar for DME and Medical Supplies
combined,
Coverage is available only at Network facilities specifically approved and designated by Us to perform
these procedures. Transplants performed at any other Network facility will not be Covered.
40 visits per Calendar Year
We will reimburse a Subscriber $200 per six-month period. We will reimburse the Subscribers spouse $100
per six-month period. The Member must complete 50 visits within the six-month period.
200 days per Calendar Year
210 days per Calendar Year (combined inpatient and outpatient)
5 sessions either before or after the death of the Member
except that Durable Medical Equipment related to Essential Benefits under the Patient Protection
and Affordable Care Act are unlimited.
60 visits per Calendar Year. Up to 20 of these visits may be used by the Member's family when the Member is
in active treatment.
30 days per Calendar Year
7 days per Calendar Year.
MAXIMUMS AND LIMITATIONS (contd)
Outpatient Mental Health
Services
Inpatient Mental Health
Services
Vision Care We will reimburse up to $50 every 12 months for a vision examination. We will reimburse up to $70 every 24
months for one set of appliances.
Outpatient Prescription Drug Deductible of $100, per Member per Contract Year. It is applicable Tier 2 and Tier 3.
30 visits per Calendar Year.
30 days per Calendar Year. Members may choose to exchange one inpatient day for two visits of partial
hospitalization
DEDUCTIBLES
The applicable Deductible for this Plan are:
Single Deductible:
Family Deductible:
$2,000 per Contract Year
2.5 times the single Deductible per Contract Year.
OUT-OF-POCKET MAXIMUMS
Please Note:
Single Out-of-Pocket Maximum:
Family Out-of-Pocket Maximum:
$3,000 per Contract Year
2.5 times the single Out-of-Pocket Maximum per Contract Year.
paid for non-Covered Services, and any amounts paid as a penalty do not count toward the Out-of-Pocket Maximum. Coinsurance paid for any
Covered Service obtained under Supplemental Coverage (excluding State mandated offers) will not be applied toward the Out-of-Pocket
Maximum.
Only Deductibles, and Coinsurance paid for Covered Services contribute to your Out-of-Pocket Maximum. Copayments, amounts
EFFECTIVE DATES OF COVERAGE
Initial Enrollment (During the initial Group Open Enrollment Period). Coverage is effective on the effective date of the Agreement.
Newly Eligible Employee
Newly Eligible Dependents
Group Open Enrollment Period.
IMPORTANT:
(Application within 31 days of becoming eligible). Coverage is effective as of the date the employee became
(Application within 31 days of becoming eligible). Coverage is effective as of the date the dependent became
eligible. Coverage is effective at birth for newborns and newly born adopted children subject to the enrollment requirements as described in
Coverage will be effective the renewal date of the Agreement/as specified by Group.
this document is not a contract. It is only a summary of your coverage under the Exclusive Plan Metro. Please read your
Certificate for a full description of your Covered Services, exclusions and other terms and conditions of coverage
ELIGIBILITY LIMITS
The limiting age for Dependents (as defined in the Certificate) is age 26.
eligible.
the Certificate.
MS-06-664 Breast Reconstruction (5.06)

Reconstructive Breast Surgery Law

Effective October 21, 1998, health insurance carriers of group and individual commercial policies
that cover mastectomies are required to cover reconstructive surgery or related services following
a mastectomy in accordance with the Womens Health and Cancer Rights Act of 1998.

The Act guarantees coverage to any Member who is receiving benefits in connection with a
mastectomy and who elects breast reconstruction in connection with that mastectomy. The health
insurance company that issues the policy is required to provide coverage (as determined in
consultation with the attending physician and the patient) for:

Individuals receiving mastectomy-related benefits, coverage will be provided in a manner
determined in consultation with the attending physician and the patient for:

a. all stages of reconstruction of the breast on which the mastectomy has been performed;
b. surgery and reconstruction of the other breast to produce a symmetrical appearance;
c. prostheses; and
d. treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided in the same manner as other medical and surgical benefits
provided under this plan.

If you would like more information about this benefit, please read the enclosed Certificate of
Coverage.

Important Information
NY-05-610 NY National Medical Support Notice 3.11

National Medical Support Notices

The New York State Insurance Department has issued guidance as to how health
insurance policyholders and health insurance companies/ health maintenance
organizations need to respond when they receive a "National Medical Support Notice"
issued by the New York State Division of Child Support Enforcement. These notices
require that a non-custodial parent provide health insurance for a dependent child. In
some cases the non-custodial parents may not have elected coverage for themselves and
may need to be enrolled in order to provide the coverage required pursuant to the
National Medical Support Notice.

Any party that fails to comply with the court order becomes responsible for any
healthcare costs incurred as a result of the non-compliance. Even when the non-custodial
parent refuses to sign a required enrollment form, the policyholder and the insurer must
take necessary steps to enroll the child even if it means enrolling the non-custodial parent
against his/her will.

Thank you for your assistance in helping us to process these enrollments in compliance
with the Insurance Department's directive.

MS-11-081 NY-NJ-SG-IND PRE-EX LETTER 02.11

RE: Request for Information about Preexisting Condition Exclusion

Dear Member,

This plan imposes a preexisting condition exclusion for members age 19 or older. This means that if you
had a medical condition before coming onto our plan, you might have to wait a certain period of time
before we will provide coverage for that condition. This exclusion applies only to conditions for which
medical advice, diagnosis, care or treatment was recommended or received within the six months prior to
your enrollment date, as defined in your Certificate of Coverage.

The preexisting condition exclusion does not apply to pregnancy for members who are part of an
employer group. (The exclusion does apply to pregnancy for members with an individual plan.) This
exclusion may last up to 12 months (180 days for members with a New Jersey Small Business plan) from
your enrollment date. You can, however, reduce the length of this exclusion period by the number of days
of prior health insurance or creditable coverage you may have had prior to enrolling with us. Most prior
health coverage is creditable coverage and can be used to reduce the preexisting condition exclusion, if
you have not experienced a break in coverage of more than 63 days.
1

To reduce the 12 month exclusion period (180 days for members with a New Jersey Small Business plan)
by your creditable coverage, you should give us a copy of any certificates of creditable coverage that you
have or call us at the telephone number on your Oxford member ID card for assistance with
demonstrating creditable coverage.

Please send us a copy of your certificate of creditable coverage or other documentation as soon
as possible. Mail it to:

Oxford
P.O. Box 7085
Bridgeport, CT 06601-7085

If you have any questions regarding this notice, please call Customer Service at the telephone number on
your Oxford member ID card. If you are hearing impaired and require assistance, please call our
TTY/TDD line at 1-800-201-4875. Please call 1-800-303-6719 for assistance in Chinese, 1-888-201-4746
for assistance in Korean, or the telephone number on your Oxford member ID card for assistance in other
languages. Customer Service Associates are available Monday through Friday, between 8:00 AM and
6:00 PM.

Sincerely,

Oxford

1
Members with a New Jersey Small Business plan cannot have a break in coverage of more than 90
days. Members with a New Jersey individual plan cannot have a break in coverage of more than 31
days.

MS-09-409 Womens Health and Federal Mandate Letter 1.11

Womens Health and Cancer Rights Act

As required by the Women's Health and Cancer Rights Act of 1998, benefits are provided for
mastectomy, including reconstruction and surgery to achieve symmetry between the breasts,
prostheses, and treatment of complications resulting from a mastectomy (including lymphedema).
If you are receiving benefits in connection with a mastectomy, benefits are also provided for the
following covered health services, as you determine appropriate with your attending physician:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
Prostheses and treatment of physical complications of the mastectomy, including
lymphedema.
The amount you must pay for such covered health services (including copayments, coinsurance
and any annual deductible) and the benefit coverage limitations are the same as are required for
any other covered health service as described in your Certificate of Coverage or Summary Plan
Description.
Newborns and Mothers Health Protection Act

Under federal law, group health plans and health insurance issuers offering group health
insurance coverage generally may not restrict benefits for any hospital length of stay in
connection with childbirth for the mother or newborn child to less than 48 hours following a
vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the
plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse
midwife, or physician assistant), after consultation with the mother, discharges the mother or
newborn earlier.
Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs
so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to
the mother or newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a physician or other health
care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours).
However, to use certain providers or facilities, or to reduce your out-of- pocket costs, you may be
required to obtain precertification. For information on precertification, call the toll-free Customer
Service telephone number on your Oxford member ID card.
Notification of Language Assistance Program
We understand that we serve an increasingly diverse membership. More than ever, we believe
that it is important to accommodate language preferences, especially when it comes to our
members accessing care and services to ensure that language is not an obstacle to receiving
proper care.
We offer language assistance services to limited English proficiency (LEP) members. Language
assistance services are provided free of charge to members. If you need assistance or have any
questions about these services, please call the toll-free Customer Service telephone number on
the back of your Oxford member ID card.
New York Handbook

OHINY MH LS 906 6632 NY OHI Small Liberty EPO Handbook 9.12

Oxford Health Insurance, Inc.

Liberty Plan Metro EPO

Member Handbook
New York Handbook

2

Table of Contents

SECTION PAGE

Welcome 3
Key Contact Information 4
How the Plan Works 5
Medical Emergencies and Urgent Care 9
Transitional Care 11
Initial Coverage Determination Timeframes 13
Appeals, Grievances and Complaints 16
ERISA Information 28
How Covered Benefits are Reimbursed 30
Notification of Federal Legislation 37
Evaluating New Medical Technology 38
Member Rights and Responsibilities 39
Information on the Web 41
Information Available Upon Request 42

New York Handbook

3

Welcome!

Thank you for choosing Oxfords Liberty Metro Plan EPO . This Member Handbook (Handbook) has been created
to assist you in accessing your Covered Services through Oxford. It will help you understand your coverage, your
rights as a Member, and your responsibilities.

Your healthcare coverage allows you to obtain coverage on either an In-Network or Out-of-Network basis. Your
Certificate of Coverage (Certificate) and Summary of Benefits contain information about your Plan Coverage. These
documents are being provided in English. Translation of these documents by any person/organization other than
Oxford (or certified translation agencies authorized by Us) is prohibited. Please contact Oxford Customer Care to
find out which documents are available in other languages.

You should be familiar with the contents of this Handbook, your Certificate of Coverage and your Summary of
Benefits. These documents describe your plan coverage and your Out-of-Pocket Expenses for receiving Covered
Services, in detail. Throughout these documents, certain terms will be capitalized and are defined in your Certificate
of Coverage.

Please feel free to contact Oxford Customer Care if you have any questions, issues or concerns. In addition, We
welcome your input and suggestions on how We can improve Our service to you. You can reach a Customer Care
Representative Monday through Friday, from 8 am to 6 pm at the number on your Oxford ID card, or at 1-800-444-
6222. Additional contact information, including phone numbers for assistance in other languages and for the
hearing impaired is included in the Key Contact section of this Handbook.
New York Handbook

4

Key Contact Information

We want you to be able to contact Us how, when and where you want to. Our website, www.oxfordhealth.com, is
available 24 hours a day, seven days a week
1
to obtain answers to your questions. If you do need to reach Us by mail
or telephone
2
, its important for you to know how. The following list is intended to make your interactions with Us a
little bit easier.

If you want

Call or Write When
To confirm eligibility, check claims
status, request materials through
Interactive Voice Response with
touch tone phone options
OR
To speak to a Customer Care
representative

Oxford Express
1-800-444-6222

Oxford Customer Care
1-800-444-6222 or the number on your
Oxford ID card
Oxford Express
24 hours a day, 7 days a week

Oxford Customer Care
Weekdays from 8 am to 6 pm
To get assistance in a language
other than English

Chinese - 1-800-303-6719
Korean - 1-888-201-4746
Spanish - 1-800-449-4390
Other Languages - 1-800-444-6222 or the
number on your Oxford ID card

To access a phone line for the
hearing impaired

TTY/TDD Hotline
1-800-201-4875
To request healthcare guidance
from a registered nurse

Oxford On-Call
1-800-201-4911
To find out about pharmacy
benefits, claims, or prescriptions
3

Pharmacy Customer Care (Medco Health)
1-800-905-0201

(except Thanksgiving and
Christmas)
To order certain mail order
maintenance medications
4

Home Delivery Customer Care (Medco
Health)
1-800-905-0201
(except Thanksgiving and
Christmas)
To obtain Referrals to behavioral
health Providers, or
Precertification for mental health
services
Behavioral Health
1-800-201-6991
1
Excludes periodic downtimes for system maintenance.
2
If you have a Medical Emergency, call 911 or seek immediate care at the nearest Emergency Room.
3
Only applicable if a pharmacy benefit has been purchased by the Group.
4
Only applicable if a mail order pharmacy benefit has been purchased by the Group.

New York Handbook

OHINY MH LEPO LS 906 5 6632 NY OHI Small Liberty EPO Handbook 9.12
In the case of an
emergency, call 911
or seek immediate
care at the nearest
emergency room.

You can confirm that a Provider
is part of Our Liberty Network
by logging onto our website or
by calling Us. Please see the
contact information at the front
of this handbook.
How the Plan Works

This section is intended to educate you about how your plan works so that your experience with
Oxford is a positive one.

The EPO/Liberty Network Plan

Coverage is being provided for you and your Covered Dependents (if any) under Our
EPO/Liberty Network Plan. This Plan requires you to receive Covered Services from
Providers within Our Liberty Network, which a subset of our larger Freedom Plan
network.

Like all Providers in Our network, We carefully select Liberty Network Providers so that
you receive access to consistent, quality cost-effective care. While this network is
smaller than Our Freedom Network, it is equal in terms of quality. Please confirm that
your Provider is part of the Liberty Network in order to receive Covered Services.

How the EPO/Liberty Network Plan Works

Obtaining Covered Services: As a Member of Our EPO/Liberty Network Plan,
you may receive Covered Primary, Preventive or Specialty Care from Liberty
Network Providers without a Referral.

Some Covered Services require Precertification. Your Summary of Benefits
shows which services must be Precertified. Your Liberty Network Provider is
responsible for obtaining all Precertifications.

Network Exceptions: If your Liberty Network Provider cannot perform or deliver the Covered Services
you need, you may receive Medically Necessary services from a non-Liberty Network Provider (including a
Freedom Network Provider). First you must contact Us and Precertify the use of the non-Liberty Network
Provider. Before Precertifying the use of a non-Liberty Network Provider, We may recommend another
Liberty Network Provider who is able to render the services you need. However, if We agree that it is
necessary for you to use a non-Liberty Network Provider (and Precertify the services), there will be no
additional cost to you beyond your required Copayment.

Additionally, Precertification requests for admissions to Non-Liberty Network facilities (e.g., hospitals,
rehabilitation centers) will not be approved unless We agree that Our Liberty Network is unable to meet
your specific medical needs, as defined in the Certificate. While you and your Liberty Network Provider may
discuss having a procedure performed at a specific Non-Liberty Network facility, coverage is only available
if We agree that the procedure cannot be safely performed at any Liberty Network facility.

Experimental and Investigational Services: Coverage for Experimental and Investigational treatments
and procedures, as defined in your Certificate, is specifically excluded under your Certificate with Oxford.
However, Oxford will cover Experimental and Investigational treatment in certain limited circumstances.
New York Handbook

OHINY MH LEPO LS 906 6632 NY OHI Small Liberty EPO Handbook 9.12
6

Please refer your
Summary of Benefits for
the specific Deductibles
and Coinsurance that
apply to your plan.
The criteria for coverage of Experimental and Investigational treatment is contained in Oxford's
Experimental and Investigational policy, which is available to Members upon request. The criteria for
coverage of Experimental and Investigational treatment that is being offered in a clinical trial is contained in
Oxford's Clinical Trial policy, is also available upon request.

What You Need to Know About Precertification

Certain Covered Services require Precertification. When you receive services from Liberty Network
Providers, obtaining Precertification is never your responsibility and you will never be penalized or held
liable for any charges because your Liberty Network Provider failed to obtain any required Precertification.

While you are not responsible for obtaining Precertification, you may want to verify that the service was
Precertified before you make plans to obtain the service in the event that We have denied the request. In
this instance, you may wish to Appeal Our decision (please see the Grievance and Appeals section).
While We will notify you of any such denials, you should feel free to check on the status of the request at
any time prior to such notification.

In addition, you should know the following about this process:

Precertifications are not valid after your coverage terminates. If We Precertify a service and your coverage
ends or terminates before you receive the service, the Precertification is no longer valid. This means that
services received after your coverage has terminated will not be Covered even if they were Precertified.
However, if coverage is continued after termination under COBRA, State Continuation or Extension of
Benefits (as described in your Certificate) the Precertification will be valid, as if the termination had not
occurred.

Precertification is valid only for the services that were actually requested and approved by Us. If you
receive a non-Covered Service instead of the Covered Service that We Precertified, we will not honor the
Precertification. Additionally, We will not reimburse non-Covered Services if We Precertify a procedure
based on inaccurate or misleading information.

Additional Plan Features
Additionally, your employer may have purchased a Health Reimbursement Account (HRA) or a Health
Savings Account (HSA). This section only applies to you if your employer has purchased a HRA or HSA
plan. Please check with your employer to see if this section applies to you.

Health Reimbursement Accounts (HRA)
HRAs are employer-sponsored plans that can be used to reimburse a portion of you or your
Dependents out-of-pocket qualified medical expenses. Qualified medical expenses are
expenses not covered by insurance. This typically includes Deductibles and Coinsurance
payments. Your employer can also choose to allow HRA funds to be used for a wide array
of other expenses such as dental, vision, prescription drugs or other expenses listed in Section
213 of the Internal Revenue Code.

Your HRA plan will require you to meet a Deductible and then pay Coinsurance for the Covered Services
you receive. Your plan includes separate Deductible and Coinsurance amounts for In-Network and Out-of-
New York Handbook

7

Please refer to Website
or call Customer Care for
a full list of all qualified
medical expenses.

For more information on
HSAs, please refer to the
United States Treasury
Departments website at
www.ustreas.gov
Network Covered Services. Preventive Care received In-Network is Covered in full under the plan and
does not require any out-of-pocket expenses. The following is an example of how your HRA plan will work:

Assume that your In-Network Deductible is $2,000 and your employer contributes $1,000 to your HRA
account. Any In-Network preventive visits will not reduce the balance in your HRA account, and you will
not be responsible for any out-of-pocket costs. However, if you see a Provider for non-preventive Covered
Services, the amount that We approve when the claim is adjudicated will be applied to your Deductible.
You may then use the HRA account to pay for that charge.

For Example: You visit an allergist who charges $250 for services which are Covered under your Plan.
The allergist is a Network Provider and the claim is approved by Us in the amount of Our contracted rate of
$200. You would be able to use the funds in your HRA account to pay the $200 charge and your remaining
Deductible to be satisfied would be $1,800. After payment of this charge you would have $800 remaining
in your HRA to use for any future eligible Covered Services. Because the Provider was a Network
Provider, you will not be billed for the difference between the billed charges and Our contracted rate.

When the funds in your HRA account are exhausted, you will be responsible for paying any remaining
amount on your Deductible. Once you have reached your Deductible, you will begin paying the
Coinsurance amount specified in your Summary of Benefits up to the Out-of-Pocket Maximum.

The reimbursements made from the HRA to you are not considered part of your income and are not taxed.
Unused funds in your account may be rolled over from year to year if your employer chooses this option
and you remain enrolled in the HRA plan. Additionally, how you access your HRA depends upon how your
employer has set up the plan. Please check with your employer for specific information regarding the
administration of your HRA plan.

Health Savings Accounts (HSA)

HSAs were created by the Medical Prescription Drug, Improvement & Modernization Act
of 2003. This tax advantaged account gives you a new way to pay for healthcare
expenses and plan for retirement. The HSA is a medical cash account that you own. You
can make contributions to the account up to the maximums determined by the United
States Treasury Department. Although not required, your employer may also choose to
contribute to your HSA account.

You may use your HSA to pay for qualified medical expenses. Qualified medical expenses,
as defined in Section 213 of the Internal Revenue Code include, but are not limited to, doctor
visits, hospital expenses, lab, x-ray, and other diagnostic services, prescription drugs, dental
care, vision care and hearing aids.

Your HSA plan will require you to meet a Deductible and then pay Coinsurance for the Covered Services
you receive. Your plan includes separate Deductible and Coinsurance amounts for In-Network and Out-of-
Network Covered Services. Preventive Care received In-Network is Covered in full under the Plan and
does not require any Out-of-Pocket Expenses. The following is an example of how your HSA plan will
work:

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Your contributions are
on a pre-tax basis and
contributions made by
your employer are not
taxable income.
Balances remaining in
the account at the end
of the year roll over to
the next year, just as in
other checking
accounts. Additionally,
the money in the
account belongs to you
you will not forfeit the
funds if you change
healthcare coverage,
change jobs, retire, etc.
Please refer your Summary of
Benefits for the specific
Deductibles and Coinsurance
that apply to your plan.

Assume that your In-Network Deductible is $2,000 and your employer contributes $500
to your HSA account. You have decided to contribute $500 to your account for a total
HSA account balance of $1,000. Any In-Network preventive visits will not reduce the
balance in your HSA account, and you will not be responsible for any out-of-pocket
costs. However, if you see a Provider for non-preventive Covered Services, the amount
that We approve when the claim is adjudicated will be applied to your Deductible. You
may then use the HSA account to pay for that charge.

For Example: You have a Covered surgery as an outpatient for which the Provider normally charges
$600. The Provider is a Network Provider and the claim is approved by Us in the amount of Our contracted
rate of $500. You would be able to use the funds in your HSA account to pay the $500 charge and your
remaining Deductible to be satisfied would be $1,500. After payment of this charge you would have $500
remaining in your HSA to use for any future eligible Covered Services. Because the Provider was a
Network Provider, you will not be billed for the difference between the billed charges and Our contracted
rate.

When the funds in your HSA account are exhausted, you will be responsible for paying any remaining
amount on your Deductible. Once you have reached your Deductible, you will begin paying
the Coinsurance amount specified in your Summary of Benefits up to the Out-of-Pocket
Maximum.

HSAs are available to you if you are covered by a qualified, high-deductible health insurance
plan. A qualified high-deductible health insurance plan is an insurance plan that requires you
to pay Deductible and Coinsurance for In-Network services (excluding preventive services)
and that meets the minimum Deductible and Out-of-Pocket Maximum requirements set by the
United States Treasury Department.

You cannot enroll in an HSA if you have other healthcare coverage that covers the same
services as the high-deductible health plan (e.g., coverage through a spouse or other
employer). Additionally, if you are enrolled in Medicare, you are not eligible to contribute to
the HSA. However, you can still spend money you have previously accumulated in your HSA
for qualified medical expenses.

How you access your HSA depends upon how your employer has set up the plan. Please check with your
employer for specific information regarding the administration of your HSA plan.
Please Remember: Providers are responsible for all health services that you receive. All services rendered are subject to your Providers
professional judgment. If you refuse to follow a recommended treatment, and the Provider believes that no professionally acceptable
alternative exists, you will be so advised. In such a case, subject to the second opinion process, neither the Provider nor We will have any
further responsibility to provide care for the condition under treatment. You will need to select another Provider to pursue treatment options.
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OHINY MH LS 906 9 6632 NY OHI Small Liberty EPO Handbook 9.12
Medical Emergencies & Urgent Care

The following section describes Oxfords coverage guidelines for emergent and Urgent Care this information is
intended to help you understand how emergent and Urgent Care may be Covered under your Oxford Plan.

Medical Emergencies

Treatment for Medical Emergencies does not require Precertification, however, you must notify Us of any inpatient
admissions resulting from a Medical Emergency. Care provided in an Emergency Room is only Covered in the case
of a Medical Emergency.

A Medical Emergency is a medical or behavioral condition the onset of which is sudden, that manifests itself by
symptoms of sufficient severity including severe pain, that a prudent layperson, possessing an average knowledge of
medicine and health, could reasonably expect the absence of immediate medical attention to result in:
placing the health of the Member with such condition in serious jeopardy, or in the case of a behavioral
condition placing the health of such Member or others in serious jeopardy;
serious impairment to the Members bodily functions;
serious dysfunction of any bodily organ or part of such Member; or
serious disfigurement of such Member.

Medical Emergencies include, but are not limited to, the following conditions:
severe chest pains
severe shortness of breath
severe bleeding
acute pain or conditions requiring immediate attention such as suspected heart attack or appendicitis
severe or multiple injuries
loss of consciousness
sudden change in mental status (e.g., disorientation)
poisonings or convulsions.

Urgent Care

Urgent Care is defined as medical care for a condition that needs immediate attention to minimize severity and
prevent complications, but is not a Medical Emergency. Urgent Care is Covered both in and out of the Service
Area.

You are not required to get Precertification prior to obtaining Urgent Care from a Network Physician. All Network
Physicians are required to have 24-hour support or an answering service so that Members have access to medical
care at all times. You may also contact Oxford On-Call to discuss treatment recommendations. Oxford On-Call is
available around the clock to offer healthcare guidance with Urgent Care situations.

In the case of an
emergency, call 911
or seek immediate
care at the nearest
Emergency Room.
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You may also receive Urgent Care Services at a network Urgent Care Center in the Service Area or at a
UnitedHealthcare Choice Plus Network Urgent Care Center outside the Service Area. If the Urgent Care Center is
part of Our Network or the UnitedHealthcare Choice Plus Network, you do not need to obtain Precertification prior
to obtaining care. However, if the Urgent Care Center is not part of Our Network or the UnitedHealthcare Choice
Plus Network, you must receive Precertification from Us for services to be Covered subject to the In-Network Out-
of-Pocket Expense specified on your Summary of Benefits. If you receive Covered Services from a Non-Network
Urgent Care Center without first obtaining Precertification from Us, coverage will be subject to the Out-of-Network
Out-of-Pocket expense specified on your Summary of Benefits.

If Urgent Care results in an emergency admission, please follow the instructions for Emergency Hospital admissions
as described in your Certificate.

Ambulance Services

Ambulance Services may include land, water or air ambulance when a Member is in need of Medically Necessary
Covered Services.

Ambulance services for 911 transportation or Medical Emergencies as defined previously in this section are Covered
and do not require Precertification.

Precertification is required, however, for non-Medical Emergency ambulance services. For example, such services
may be Covered, if the Member is bed-confined and other means of transportation are inappropriate or if the
Member has a medical condition that makes transportation by ambulance medically required. Non-Medical
Emergency ambulance services may not be Covered for Hospital transfers that are not Medically Necessary. This
may include transfers that are based on Member preference or convenience and not related to certain services or
discharges from a Hospital to the home or recovery facility.

Non-ambulance transportation, such as ambulette or cab services are not Covered. Please contact Us for a
description of Our current policies on non-emergency ambulance services.
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11

Transitional Care
This explains Oxfords Transitional Care policy this may apply if your Network Provider leaves Oxfords Provider
network or if you are new to Oxford and are undergoing a course of treatment as described
below. Transitional Care is intended to assist you during this process, making it as seamless
as possible for you.

If Your Provider Leaves the Network

Selecting A New Provider: If your PCP or Network Specialist leaves Our Network, you will
need to select another PCP or Network Specialist in order to continue receiving care on an In-
Network basis. We will send you written notification that includes information on how to
select a new PCP or Specialist.

Transitional Care: If you are undergoing a course of treatment when your Network Provider
leaves Our Network, you may be able to continue to receive Covered Services on an In-
Network basis from your former Network Provider. For purposes of this section, undergoing
a course of treatment refers to a defined course of treatment for a specified diagnosis.

If the coverage is determined to be Medically Necessary and the Provider agrees to follow
Our reimbursement rates, policies and procedures, you will receive the Covered Services
as if they are being provided by a Network Provider subject to any applicable Out-of-Pocket
Expenses and any applicable Precertification requirements. If we terminated a Provider due
to a quality-of-care issue, Transitional Care is not available.

Depending on your condition, you may receive Transitional Care for up to 120 days from
the date the Provider ceases to be in the Network. If the Provider leaves the Network while
you are in the second or third trimester, you may receive Covered Services through delivery
and any post-partum care directly related to the delivery.

If You Switch to a Different Network Within Oxford

If you are enrolled in Our Freedom Network, but enroll in Our Liberty Network upon
renewal of your coverage, you may need continuing access to a Provider that was participating in your old Freedom
Network but that is not participating in your new Liberty Network. In this case you may receive coverage for
services rendered by your former Provider on an In-Network basis for up to 120 days from the date of re-enrollment
subject to the out-of-pocket expenses specified on your Summary of Benefits and any applicable Precertification
requirements. Please refer to your Summary of Coverage to determine the Network that applies to your Plan.

New Members Undergoing Treatment With A Non-Network Provider

If you are undergoing a course of treatment with a non-Network Provider when your Oxford coverage initially
becomes effective, you may be able to receive Covered Services on an In-Network basis from this Provider for up
to sixty days from the effective date of your coverage. You will be responsible for applicable In-Network out-of-
pocket expenses as specified on your Summary of Benefits. In addition, any applicable Precertification
requirements will apply.

This coverage is available only if the course of treatment is for a life-threatening or degenerative and
disabling disease or condition as determined by Us. Coverage is limited to the disease or condition and the
Provider must agree to accept Our reimbursement rates as well as adhere to Our polices and procedures
regarding the delivery of Covered Services.

Please Note: To request
Transitional Care, you or your
Provider must contact Us as
soon as reasonably possible.
Please Note: When a PCP
leaves Our Network, all
Members that have selected that
Provider to be their PCP will
receive notification. When a
Network Specialist leaves Our
Network, all Members who were
seen by that Network Specialist
in the last six months will receive
notification.
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12

If your coverage becomes effective while you are in the second or third trimester of pregnancy, you may
receive Covered Services directly related to your pregnancy from the non-Network Provider, including
delivery and post-partum care.

Receiving Transitional Care

Before coverage is provided for any transitional care as described above, your Provider must submit the required
Transitional Care Forms to Us and agree in writing to:
adhere to Our quality assurance procedures;
accept Our reimbursement rates as payment in full; and
accept Our policies and procedures regarding delivery of Covered Services.

If the Provider does not agree to the above terms, We are not obligated to approve coverage for transitional care.
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13

Please Note: In all
cases, if no information
is received within the
required timeframes, the
claim or request for
service will be denied.
Initial Coverage Determination Timeframes

This section is intended to educate you about the timeframes within which initial coverage determinations will be
made. Please note, that there are two different types of coverage determinations discussed in this section: benefits
and administrative issues and Utilization Review determinations.

Benefits and Administrative Issues

What are benefit and administrative issues?

Benefit issues include, but are not limited to, denials based on benefit exclusions or limitations and claims payment
disputes. Administrative issues concern other requirements of your health Plan such as access to providers. Benefit
and administrative issues do not include determinations concerning the Medical Necessity of
services.

Will I need to submit additional information?

We may request additional information to evaluate your issue. If we request additional
information, you will have up to 45 days from the date you receive Our request to provide the
additional information. For Urgent Care services, you will have 48 hours to provide the requested
information.

Please Note: Regarding benefit issues, if you do not submit the requested additional information
within the above timeframes, your claim or request for services will be denied. Regarding
administrative issues, We will assume you are no longer concerned or interested in pursuing the issue.

When will initial determinations for benefit and administrative issues be made?

Initial determinations for benefit and administrative issues will be made in the following timeframes:

If no additional
information is
requested

If additional information is requested
Requests for Service (Pre-Service): Within 15 days of Our
receipt of the request.
Within 15 days of Our receipt of the
information, or upon the expiration of the period
allowed to provide the information (i.e., 45
days).

Coverage for Services Rendered (Post-
Service):
Within 30 days of Our
receipt of the claim.
information, or upon the expiration of the period
allowed to provide the information (i.e., 45
days).

Requests for Urgent Care (Pre-service) -
(includes any claim for medical service that if
subjected to standard timeframes, could
seriously jeopardize your life or health):
Within 72 hours of Our
Within 48 hours of Our receipt of the
information, or the expiration of the original
request for additional information, whichever is
sooner (i.e., 45 days).

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Please Note: In all
cases, if no information
is received within the
required timeframes, the
claim or request for
service will be denied.
How will I be notified of Oxfords determination?

We will inform you of Our decision in writing by mail or electronic means. The notice of Our initial benefit
determination will provide the reasons for the decision. This will include clinical rationale if applicable, and
specific plan provisions on which the determination was based. It will also include information on how to file a
First Level Grievance, and how, with respect to benefit denials, you can request (free of charge) reasonable access
to, and copies of, all documents, records, and other information relevant to your claim.

When we receive an initial Post-Service claim from a Network Provider, in some instances, We may deny the claim.
In this situation, you may not receive a notice from Us. You cannot be held responsible for any amount above your
Copayment and you will not incur any additional financial liability. If a participating provider attempts to balance
bill you for an amount above your Copayment or Coinsurance, please contact Us.

Initial Utilization Review (Medical Necessity) Determinations

What are utilization review issues?

Utilization Review issues include items that concern Medical Necessity Determinations and, when your condition
meets the New York state definition of a Life-Threatening or Disabling Condition or Disease, decisions
involving treatment or services that are considered experimental or investigational. Although many determinations
are made prior to services being rendered, Medical Necessity Determinations may be made after services are
rendered. All services are subject to a review by Us to determine the Medical Necessity of proposed services,
services currently being provided, or services already provided. Denials will be made by the appropriate clinical
personnel.

Who conducts Utilization Review?

Utilization Review will be conducted by the following:

Administrative personnel trained in the principles and procedures of intake screening and data collection.
Administrative personnel will only perform intake screening, data collection and non-clinical review
functions and will be supervised by a licensed health care professional.
A health care professional who is appropriately trained in Our principles, procedures and standards. A
health care professional who is not a Clinical Peer Reviewer cannot render an Adverse
Determination.
A Clinical Peer Reviewer where the review involves an Adverse Determination.

Will I need to submit additional information?

We may request additional information from your Provider to evaluate your issue. If we request
additional information, your Provider will have up to 45 days from the date of Our request to
provide the additional information. For Urgent Care services, your Provider will have 48 hours to
provide the requested information.

Please Note: If your Provider does not submit the requested additional information within the
above timeframes, your claim or request for services will be denied.

When will I be notified that a service is not Medically Necessary or is experimental or investigational?

Notification of Our decision that a service is not Medically Necessary or is experimental or investigational will be
provided as follows:

If no additional information is
requested

If additional information is
requested
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Requests for service (Pre-Service): Within 2 business days of Our
receipt of the necessary information,
not to exceed 15 calendar days from
receipt of the request
Within 2 business days of Our
receipt of the information, or 2
business days from the expiration of
the period allowed to provide the
information (i.e., 45 days).

Current services for a Member in
an ongoing course of treatment:
Within 1 business day of Our receipt
of the necessary information.
Within 1 business day of Our receipt
of the information, or the expiration
of the original request for

Urgent Care for a Member in an
ongoing course of treatment:
As soon as possible but not to
exceed 24 hours of Our receipt of
the request if the request is made at
least 24 hours before expiration of
the prescribed period or number of
treatments.
Within 48 hours of Our receipt of
the information, or the expiration of
the original request for information
(i.e., 45 days).

Coverage for services rendered
(Post-Service):
claim.
information, or expiration of the
period allowed to provide the

If We do not make a determination within the above timeframes, the request will be deemed an Adverse
Determination subject to the applicable Appeal provisions.

How will I be notified of Oxfords determination?

We will inform you and your Provider of Our decision in writing by mail or electronic means. The notice of Our
initial determination will provide the reasons for the decision. This will include the clinical rationale, if applicable,
and specific plan provisions on which the determination was based. It will also include information on how to file a
First Level Appeal, and how you can request (free of charge) reasonable access to, and copies of, all documents,
records and other information relevant to your claim.

In the event that We render an Adverse Determination without attempting to discuss the matter with the Provider
who specifically recommended the Health Care Service, procedure or treatment under review, the Provider will have
the opportunity to request a reconsideration of the Adverse Determination. Except in cases of retrospective reviews,
the reconsideration will occur within one business day of receipt of the request and will be conducted by your
Provider and the Clinical Peer Reviewer making the initial determination or a designated Clinical Peer Reviewer if
the original Clinical Peer Reviewer is not available. In the event that the Adverse Determination is upheld after
reconsideration, We will provide notice as outlined in this section. Nothing in this section will preclude you from
initiating an Appeal of an Adverse Determination.
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16

All information pertaining
to Grievances, Appeals
and Complaints will be
fully documented and
retained for at least three
years.
A copy of Our consent
forms to designate a
representative are available
on Our web site or by
calling Us at the number in
the front of your Handbook.
Appeals, Grievances and Complaints

Our Grievance, Appeal and Complaint Procedures provide Members with a meaningful, dignified
and confidential process to hear and resolve issues between Members, Us and Providers in a timely
manner. This Section describes (1) The Utilization Review (UR) Appeals process, (2) the Grievance
procedure for benefit, network and administrative Issues, and (3) the Complaint procedure. The
process you will need to use depends upon the type of issue you are trying to resolve. Please read the
information in this Section carefully, as it describes what the different review procedures are and
when and how to use them. If you are still not sure of the process to follow, contact Us at 1-800-444-
6222.

Copies of these procedures are available in many languages and can be forwarded to you subject to
availability. We can also arrange to have an independent interpreter available, however Our ability
to provide this service depends on the availability of the interpreter. We may need to arrange to call you at a time
when an interpreter is available. Additionally, you always have the right to designate a representative during this
process.

Additionally, Members may write to either (or both) the New York State Insurance Department or the Department
of Health, Office of Managed Care, Bureau of Managed Care Certification and Surveillance at any time during the
Appeal, Grievance and Complaint process at the following addresses or phone numbers:

New York State Department of Financial Services,
Empire State Plaza, Corning Tower Room 1911,
Albany, NY 12237-0062

1-800-206-8125
www.dfs.ny.gov
Consumer Assistance Unit NYS Department of
Financial Services
25 Beaver Street
New York, NY 10004-2319
1-800-342-3736
www.dfs.ny.gov

Designees
You have the right to use these procedures. It is your responsibility to initiate a Grievance, Appeal or Complaint
within the timeframes set forth in this Certificate.

You may designate a person to act on your behalf, including your healthcare Provider (Designee). For appeals of
benefit determinations concerning Urgent Care, We are required to allow your healthcare Provider, with knowledge
of your condition, to act as your authorized representative without your written consent. A benefit determination
concerning Urgent Care is defined as a determination which, if subject to the standard appeal time frames, could
seriously jeopardize your life or health or your ability to regain maximum function, or in the opinion of a Physician
with knowledge of your condition, would subject you to severe pain that cannot be adequately
managed without the care or treatment that is the subject of the determination.

For all other circumstances, to authorize a Designee to act on your behalf, you must provide Us
with written consent at the time your Grievance, Appeal or Complaint is submitted. Because
your medical records are privileged and confidential, and We want to ensure that you wish to
Appeal, each Member must submit an original signed written consent. Members who are 18
years of age or older, including a Members spouse or children, will need to provide their own
signed written consent. If the Member is a minor a written consent must be signed by the
Members parent or guardian.

Your Designee will only be authorized to act on your behalf and is required to comply with all
of the conditions of your Certificate that would apply to you when you initiate any Grievance,
Appeal or Complaint. Your Designee is not entitled to obtain any benefits or rights under your
Certificate.
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17

Part 1 Utilization Review (UR) Appeals

UR will occur whenever judgments pertaining to Medical Necessity and the provision of services or treatments are
rendered. The Utilization Review Appeals process should be used after you have received an initial Adverse UR
Determinations as described in the Initial Coverage Determination Timeframes section on page 12, if you do not
agree with Our decision. Adverse Determinations concerning cosmetic, custodial and convenience items are
included in the determinations eligible for review through this process. All Appeals are subject to a review by Us to
evaluate the Medical Necessity of the services.

Our UR Appeal process provides for two levels of internal review or one level of internal Review and one level of
External Review by an outside clinical reviewer. The Second-Level internal review will be waived by both
parties if you choose to pursue an External Appeal. You may use this process to Appeal Adverse Determinations
relating to all UR determinations, regardless of whether the services requested by you or on your behalf have not
yet been rendered (Precertification), are currently being rendered (concurrent care) or have been rendered
(Retrospective Adverse Determinations).

Please Note: This UR Appeals process should not be used for Appeals relating to benefit and administrative issues.
Please refer to Part 2 of this section for information on the Grievance and Appeal Procedure for Benefit, Network
and Administrative Issues.

Definitions - The following Definitions apply to UR determinations and Appeals.

Adverse Determination - Our determination that an admission, extension of stay, or other Health Care Service, is
not Medically Necessary based on a review of the information provided. Additionally, an Adverse Determination
will be rendered if We do not receive a response to Our request for information necessary to review your case.

Clinical Peer Reviewer - For Internal UR Appeals, a Clinical Peer Reviewer is either:
a Physician with a current and valid non-restricted license to practice medicine; or
a health care professional (other than a licensed Physician) with a current and valid non-restricted license,
certificate or registration or, who is appropriately credentialed. This health care professional must be in the
same profession and same or similar specialty as the Provider who typically manages the medical condition
or disease, or provides the health care service or treatment under review.

For External UR Appeals, a Clinical Peer Reviewer is either:
a Physician who meets the following criteria:
o possesses a current and valid non-restricted license to practice medicine, and where applicable, is
board certified or board eligible in the same or similar specialty as the Provider who typically
manages the medical condition or disease, or provides the health care service or treatment under
Appeal; and
o has been practicing in such area of specialty for a period of at least five years and is
knowledgeable about the Health Care Service or treatment under Appeal.
a health care professional (other than a licensed Physician) who:
o has a current and valid non-restricted license, certificate or registration (if applicable); and
o is credentialed by the national accrediting body (if applicable) appropriate to the profession and is
in the same profession and same or similar specialty as the Provider who typically manages the
medical condition or disease or provides the Health Care Service or treatment under Appeal; and
o has been practicing in such area of specialty for a period of at least five years and is
knowledgeable about the Health Care Service or treatment under Appeal; and
o is clinically supported by a Physician who possesses a current and valid non-restricted license to
practice medicine (as applicable).

Clinical Standards - Those guidelines and standards set forth in Our UR Plan.

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Clinical Trial - A peer-reviewed study plan which has been reviewed and approved by a qualified institutional
review board, and approved by one of the National Institutes of Health (NIH), or an NIH cooperative group or an
NIH center, or the Food and Drug Administration in the form of an investigational new drug exemption, or the
federal Department of Veteran Affairs, or a qualified nongovernmental research entity as identified in guidelines
issued by individual NIH Institutes for center support grants, or an institutional review board of a facility which has
a multiple project assurance approved by the Office of Protection from Research Risks of the National Institutes of
Health.

As used in this section, the term "cooperative groups" means formal networks of facilities that collaborate on
research projects and have established NIH-approved peer review programs operating within their groups; and that
include, but are not limited to, the National Cancer Institute (NCI) Clinical Cooperative Groups, the NCI
Community Clinical Oncology Program (CCOP), the AIDS Clinical Trials Groups (ACTG), and the Community
Programs for Clinical Research in AIDS (CPCRA).

Disabling Condition or Disease - A condition or disease which, according to the current diagnosis of your
Physician, is consistent with the definition of "disabled person" pursuant to the social services law.

Experimental and Investigational Treatment Review Plan - A description of the process for developing the
written clinical review criteria used in rendering an Experimental and Investigational treatment review
determination. The Experimental and Investigational Treatment Review Plan also includes a description of the
qualifications and experience of the Clinical Peers who developed the criteria, who are responsible for periodic
evaluation of the criteria, and who use the written clinical review criteria in the process of reviewing proposed
Experimental and Investigational Health Care Services.

External Appeal - An Appeal conducted by an External Appeal Agent.

External Appeal Agent - An entity certified by the State of New York to conduct External Appeals.

Final Adverse Determination - An Adverse Determination which has been upheld by Us with respect to a Health
Care Service following a standard or Expedited Appeal.

Health Care Service - For purposes of UR determinations and Appeals, Health Care Service includes health care
procedures, treatments, services, Prescription Drugs, or Durable Medical Equipment. Additionally, for purposes of
External Appeals, Health Care Services are Experimental or Investigational procedures, treatments or services,
including the following (to the extent the services are prohibited from being excluded under the Plan):
services provided within a clinical trial, and
the provision of a Prescription Drug for a use other than those uses which have been approved for
marketing by the federal Food and Drug Administration.

A Health Care Service is not necessarily a Covered Service under this Plan.

Life-Threatening Condition or Disease - A condition or disease which, according to the current diagnosis of your
Physician, has a high probability of causing your death.

Retrospective Review - A review of services after such services have already been provided. We may reverse Our
determination of a Precertified service, treatment or supply after Retrospective Review only when:
the relevant medical information presented to US upon Retrospective Review is materially different from
the information that was presented during the Precertification review; and
such relevant information presented to Us existed at the time of the Precertification but was withheld from
or not made available to Us; and
We were not aware of the existence of the information at the time of the Precertification review; and
had We been aware of the information, the service, treatment or supply that was requested would not have
been Precertified. This determination will be made using the same specific standards, criteria or procedures
as were used during the Precertification review.
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Utilization Review (UR) - The review to determine whether Health Care Services that have been provided
(Retrospective), are being provided (Concurrent) or are proposed to be provided (Precertification) are Medically
Necessary.

UR Plan - A UR Plan includes the following:
a description of the process for developing the written clinical review criteria;
a description of the types of written clinical information We might consider in Our review, including but
not limited to, a set of specific written clinical review criteria;
a description of the practice guidelines and standards We use in carrying out a determination of Medical
Necessity;
the procedures for scheduled review and evaluation of the written clinical review criteria; and
a description of the qualifications and experience of the health care professionals who developed the
criteria, who are responsible for periodic evaluation of the criteria and of the health care professionals or
others who use the written clinical review criteria in the process of Utilization Review.

Our Internal UR Appeal process provides for both a First-Level UR Appeal and a Second-Level UR Appeal.
Additionally, the First-Level UR Appeal may be expedited as described in this section. All UR Appeals will be
conducted by Clinical Peer Reviewers other than the Clinical Peer Reviewer who rendered the initial Adverse
Determination.

First-Level UR Appeals

A First-Level UR Appeal may be made within the standard timeframes or may be expedited as described in this
section. All non-Expedited First-Level UR Appeals must be initiated by you or your Designee 180 days from
receipt of an Adverse Determination (i.e., receipt of the determination notice). All requests for Expedited First-
Level UR Appeals must be initiated within 45 days from receipt of an Adverse Determination, or from the date
when the condition necessitating the need for an expedited Appeal arose. You may still pursue a standard UR
Appeal within 180 days from receipt of an Adverse Determination if you choose not to pursue an Expedited Appeal
or circumstances have changed and do not justify an expedited review (i.e., you have already received the services).

While a First-Level UR Appeal may be filed by telephone or in writing, We strongly recommend that you file your
Appeal in writing. The written request will give us a clearer understanding of the issues being Appealed. To initiate
the First-Level UR Appeal process, you may call the Us at 1-800-444-6222, fax Us at 1-203-459-5423 (for
Expedited First-Level UR Appeals) or write to Us at:

Oxford Health Plans, Attn: Clinical Appeals, P.O. Box 29139Hot Springs, AR 71903-29139

Please Note: Our toll-free telephone line is available for forty hours per week during normal business hours. After
normal business hours we have an answering machine available to record your call. We will respond to recorded
messages within one business day after the date on which the call was received. Additionally, if you have any
questions regarding where to seek care, you may receive health care guidance from a registered nurse 24 hours a
day, seven days a week, at the number in the front of your Handbook.

In addition to your request for an Appeal, you or your designee must send any documentation/information already
requested by Us (if not previously submitted) and any additional written comments and documentation/information
you would like to submit in support of the Appeal. At the time of Our review, We will review all available
comments, documentation and information.

Unless We have already issued a written determination, We will use our best efforts to provide written
acknowledgment of the receipt of your Appeal within 5 business days, but in no event later than 15 calendar days.
Our decision to either uphold or reverse the Adverse Determination will be made as follows:
Requests for service (Precertification): Within 15 days of Our receipt of the Appeal.
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Current services for a Member in an ongoing course of treatment (Concurrent): Within 2 business days
of Our receipt of all necessary information.
Coverage for services rendered (Retrospective): Within 30 days of Our receipt of the Appeal.
Our determination will be communicated to you, your Designee and/or Provider (if applicable) within 2 business
days of Our rendering of the determination within the above timeframes. If we do not make a determination on your
First-Level UR Appeal within the timeframes outlined in this section, the Adverse Determination will be reversed.

Expedited First-Level UR Appeal

You can expedite your First-Level UR Appeal when:

you receive an Adverse Determination involving continued or extended Health Care Services, procedures
or treatments or additional services while you are undergoing a course of continued treatment (Concurrent);
or
the timeframes of the non-expedited UR Appeal process would seriously jeopardize your life, health or
ability to regain maximum function; or
in the opinion of a Physician with knowledge of the health condition, the timeframes of the non-expedited
UR Appeal process would cause you severe pain that cannot be managed without the care of treatment that
was requested.
your Physician believes an immediate Appeal is necessary because the timeframes of the non-expedited UR
Appeals process would significantly increase the risk to your health.

The expedited procedure cannot be used to seek review of Adverse Determinations for services which have already
been provided (Retrospective).

The Expedited First-Level UR Appeal process includes procedures to facilitate a timely resolution of the Appeal
including, but not limited to, the sharing of information between your Provider and Us by telephone or facsimile.
We will provide reasonable access to Our Clinical Peer Reviewer within one business day of receiving notice of an
Expedited First-Level UR Appeal.

Expedited First-Level Utilization Review Appeals will be determined within two business days of receipt of
necessary information or 72 hours from Our receipt of the Appeal, whichever is shorter. If you are not satisfied
with the outcome of the Expedited First-Level UR Appeal, you may further Appeal through either the Second-Level
UR Appeal process, or the External Appeal process. If We do not make a determination within two business days
of Our receipt of the necessary information, the Adverse Determination will be reversed.

The notice of an Appeal determination will include the reasons for the determination. If the Adverse Determination
is upheld on Appeal, the notice will include the clinical rationale for the determination. This is considered Our Final
Adverse Determination (FAD). We will also include a notice of your right initiate an External Appeal or an internal
First-Level UR Appeal along with a description of each process and the associated timeframes.

If We generally reversed an Adverse Determination but part of your request remains denied, you or your Designee
may either submit (1) an External Appeal pursuant to New York State Law or (2) a written Second-Level UR
Appeal for the services that remain denied.

Second-Level UR Appeals

You or your Designee may submit a Second-Level UR Appeal to Us if an External Appeal has not been filed
through the New York State External Appeal Process. The request for a Second-Level UR Appeal and any
additional information must be submitted to:

Oxford Health Plans, Grievance & Appeal Review Board, 48 Monroe Turnpike, Trumbull, CT 06611

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You or your Designee will need to include all information previously requested by Us (if not previously submitted),
and include any additional facts or information that you believe to be relevant to the issue. You or your Designee
may send Us written comments, documents, records or other information regarding the claim. We will consider all
available information relevant to your Appeal when making Our review.

If during the processing of your Second-Level UR Appeal, you or your Designee files an External Appeal through
the New York State External Appeal Process, your Second-Level UR Appeal to Us will be deemed to have been
waived and We will not render a decision.

A Second-Level UR Appeal must be filed within sixty business days of the date on which you received notice of
the First-Level UR Appeal determination. Unless We have already issued a written determination, We will use our
best efforts to provide written acknowledgment of the receipt of your Second-Level UR Appeal within 5 business
days, but in no event later than 15 calendar days.

We will provide you, your Designee, or your Provider (if applicable) with Our written decision (by mail or
electronic means) which will include the detailed reasons for Our decision. This will include clinical rationale (if
applicable) and references to any specific Plan provisions on which Our decision was based. We will also include
information on how you can request (free of charge) reasonable access to, and copies of: all documents, records, and
other information relevant to your claim for benefits. Our decisions will be communicated as follows:

Current services for a Member in an ongoing course of treatment (Concurrent): Within 15 days of Our
receipt of the Appeal.

Please note: only the First-Level UR Appeal may be expedited. If, at the Second-Level, you would like to obtain an
expedited response, please follow the External Appeal process.

This ruling will be Our final position. All information pertaining to each Appeal will be fully documented, and
retained for at least three years.

External UR Appeals

You, your Designee and, in connection with Retrospective Adverse Determinations, your Provider, have the right to
request an External UR Appeal in the following situations:
you have had coverage of a Health Care Service denied on Appeal on the grounds that the Health Care
Service is not Medically Necessary, and We have rendered a FAD with respect to the Health Care Service
(or both We and you have agreed to waive any internal Appeal); or
Experimental or Investigational determinations:
o you have had coverage of a Health Care Service denied on the basis that such service is
Experimental or Investigational, and the denial has been upheld on Appeal (or both We and you
have agreed to waive any internal Appeal); and
o your Physician has certified that you have a Life-Threatening or Disabling Condition or disease (a)
for which standard health services or procedures have been ineffective or would be medically
inappropriate, or (b) for which there does not exist a more beneficial standard health service or
procedure Covered by Us, or (c) for which there exists a clinical trial; and
o your Physician, who must be a licensed, board-certified or board-eligible Physician qualified to
practice in the area of practice appropriate to treat the Life-Threatening or Disabling Condition or
Disease, must have recommended either (a) a Health Care Service or procedure (including a
pharmaceutical product) that, based on two documents from the available medical and scientific
evidence, is likely to be more beneficial to you than any Covered standard health service or
procedure; or (b) a Clinical Trial for which you are eligible. Any Physician certification provided
under this section must include a statement of the evidence relied upon by the Physician in
certifying the recommendation; and
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Please Note: The 45 day timeframe for
requesting an External Appeal begins
upon receipt of the FAD regardless of
whether you decide to initiate an internal
Second-Level Appeal as described in
this section. If you decide to initiate a
Second-Level UR Appeal, you do not
waive the option to file an External
Appeal with the New York State DOI.
However, you may miss the 45 day
timeframe for requesting an External
Appeal.

o the specific Health Care Service or procedure recommended by the attending Physician would
otherwise be Covered except for Our determination that the Health
Care Service or procedure is Experimental or Investigational.

Regarding Medical Necessity decisions, We may charge you a fee of up to fifty
dollars per External Appeal. In the event the External Appeal Agent overturns the
FAD, the fee will be refunded. We will not require you to pay a fee if you are a
recipient of medical assistance or is covered by a policy pursuant to the child health
insurance plan program. Additionally, We will not require you to pay a fee if the fee
will pose a hardship to you as determined by Us.

Regarding Experimental and Investigational decisions, payment for an External Appeal
Will be Our responsibility. We will make payment to the External Appeal Agent within
45 days from the date We receive the Appeal determination. We will be obligated to
pay the amount together with applicable interest in the event that payment is not made
within 45 days.
How to File an External Appeal

Non-Expedited: You have 45 days to initiate an External Appeal after you receive
notice from Us of a FAD or denial or after both We and you agree to waive any
internal Appeal.

Requests for External Appeals must be in writing on an External Appeal application
form. The application form will include instructions on how to complete and submit
the form to the superintendent. You or your Designee (and Provider, if applicable)
must release all pertinent medical information concerning your medical condition and request for services. The
application form is available from any of the following
New York State Department of Insurance at 1-800-400-8882 or www.ins.state.ny.us;
New York State Department of Health at www.health.state.ny.us; or
Our Customer Care Department at the number in the front of this Handbook.

Requests for External Appeals that have been determined by the superintendent to be eligible for External Appeal
will be randomly assigned to a Certified External Appeal Agent according to a process prescribed by the
commissioner and superintendent.

We will forward the medical and treatment plan records We relied upon in making our determination to the External
Appeal Agent. You, and your Provider where applicable, will have the opportunity to submit additional
documentation to the External Appeal Agent within the 45 days period. If the documentation represents a material
change from the documentation upon which We based Our Adverse Determination or denial, We will have three
business days to consider the documentation and amend or confirm Our Adverse Determination or denial.

The External Appeal Agent will make a determination with regard to the Appeal within thirty days of the receipt of
your request. However, the External Appeal Agent may request additional information from you, your Provider and
Us within the thirty day period. In this case, the External Appeal Agent will have up to five additional business
days to make a determination. In either scenario, the External Appeal Agent will notify you and Us, in writing, of
the Appeal determination within two business days of making the determination.

Expedited: If your Physician states that a delay in providing the Health Care Service would pose an imminent or
serious threat to your health, the External Appeal will be completed within three days of the request and the
External Appeal Agent will make every reasonable attempt to immediately notify you and Us of its determination by
telephone or facsimile, followed immediately by written notification of the determination.

Review Process

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Do not use this procedure to
Appeal Medical Necessity
determinations or Experimental
and Investigatiional determinations.

Medical Necessity: For External Appeals requested in connection with a Health Care Service being deemed not
Medically Necessary, the External Appeal Agent will review Our FAD and will make a determination as to whether
We acted reasonably and with sound medical judgment and in your best interest. When the External Appeal Agent
makes its determination, it will consider: Our clinical standards; the information provided concerning you; the
attending Physician's recommendation; applicable and generally accepted practice guidelines developed by the
federal government; or national or professional medical societies, boards and associations. Any such determination
will:
be conducted only by one or a greater odd number of Clinical Peer Reviewers.
be accompanied by a notice of Appeal determination which will include the reasons for the determination.
Where the FAD is upheld on Appeal, the notice will include the clinical rationale (if any) for the
determination.
be subject to the terms and conditions generally applicable to benefits under your Certificate.
be binding on Us and you.
be admissible in any court proceeding.

Experimental or Investigational: For External Appeals requested in connection with a Health Care Service that
has been determined to be Experimental or Investigational, the External Appeal Agent will review the proposed
Health Care Service or procedure for which coverage has been denied and, in accordance with the External Appeal
Agent's investigational treatment review plan, make a determination as to whether the patient costs of such Health
Care Service or procedure will be Covered by Us. Any such determination will:
be conducted by a panel of three or a greater odd number of Clinical Peer Reviewers.
be accompanied by a written statement that either:
o upholds our denial of coverage; or
o indicates that the patient costs of the proposed health service or procedure must be covered by Us
either: when a majority of the panel of reviewers determines, upon review of the applicable
Medical and Scientific Evidence (or upon confirmation that the recommended treatment is a
Clinical Trial), your medical record, and any other pertinent information, that the proposed health
service or treatment (including a pharmaceutical product) is likely to be more beneficial than any
standard treatment or treatments for your Life-Threatening or Disabling Condition or Disease (or,
in the case of a Clinical Trial, is likely to benefit you in the treatment of your condition or
disease); or when a reviewing panel is evenly divided as to a determination concerning coverage
of the health service or procedure.
be subject to the terms and conditions generally applicable to benefits under your Certificate.

With respect to a Clinical Trial, patient costs include all costs of Health Care Services required to provide treatment
to you according to the design of the trial. Such costs do not include the costs of any investigational drugs or
devices, the cost of any non-health services that might be required for you to receive the treatment, the costs of
managing the research, or costs which would not be Covered under the policy for non-investigational
treatments.

No External Appeal Agent or Clinical Peer Reviewer conducting an External Appeal will be liable in damages to
any person for any opinions rendered by such External Appeal Agent or Clinical Peer
Reviewer upon completion of an External Appeal unless such opinion was rendered in
bad faith or involved gross negligence.

Part 2 - Grievance and Appeal Procedure - Benefit, Network and Administrative
Issues

The Grievance and Appeal procedure is a procedure to be used after you have received
an initial Adverse Determination concerning a claim for benefits or an administrative
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issue. Benefit issues include, but are not limited to: denials based on benefit exclusions or limitations and claims
payment disputes. Administrative issues concern other requirements of your health plan. Administrative issues
would include issues such as access to providers, eligibility or enrollment issues.

Please Note: Benefit and administrative issues do not include determinations concerning the Medical Necessity of
Covered Services. If We have denied your claims or request for services because We believe the services are not
Medically Necessary, do not use the Grievance Procedure. Please refer to Part 1 of this Section for information on
how to file a UR Appeal.

Our Grievance and Appeal procedure provides for two levels of internal review by Us. A First-Level review by Us
is called a Grievance. The Second-Level review is called an Appeal. The process may follow standard timeframes
or may be done on an expedited basis.

An Expedited Grievance and Appeal Procedure is available and should be used when the standard timeframes for
response would:
significantly increase the risk to your life, health or ability to regain maximum function; or
in the opinion of a doctor with knowledge of your health condition, cause you severe pain that cannot be
managed without the care or treatment that was requested.

The Expedited Grievance and Appeal Procedure cannot be used to seek review of Adverse Determinations when the
services have already been provided (Retrospective).

Grievance (First-Level Reviews)

While a Grievance may be filed by telephone or in writing, We strongly recommend that you or your Designee file
your Grievance in writing. The written request will give Us a clearer understanding of the issues being Appealed.
To initiate the Grievance regarding benefits and administrative issues (except for those related to quality of care)
you or your Designee may call Us at 1-800-444-6222 or write to Us at:

Oxford Health Plans, P.O. Box 29134, Hot Springs, AR 71903-29134

Quality of Care: To initiate a Grievance concerning the quality of care you received from a Network Provider,
you or your Designee must submit a written Grievance to Us at the following addresses:

Complaints Regarding Individual Providers and Facilities: Oxford Health Plans, Quality Care/Service
Department, P.O. Box 400046, San Antonio, TX 78229

Complaints Regarding Dental Providers: Oxford Health Plans, Dental Department, 48 Monroe Turnpike,
Trumbull, CT 06611

You or your Designee must submit any documentation/information already requested by Us (if not previously
submitted) and any additional written comments and documentation/information you would like to submit in support
of the Grievance. At the time of Our review, We will review all available comments, documentation and
information.

Unless We have already issued a written determination, We will provide written acknowledgment of the receipt of
your Grievance within 15 business days. The acknowledgment will include the name, address and telephone
number of the department designated to review the Grievance.

Standard: All standard Grievances must be initiated by you or your Designee 180 days from receipt of an Adverse
Determination (ie, an Explanation of Benefits, Denial Notice), or, for other issues, 180 days from the date when you
became aware of the issue that initiated the Grievance.

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You or your Designee have
60 business days from the
date you received notice of
Our Grievance decision to
file an Appeal.

Expedited: All requests for Expedited Grievances must be initiated within 45 days from when the condition
necessitating the need for an Expedited Grievance arose. However, if We do not agree to an Expedited review, you
may still submit a standard Grievance as described in this section.

We will provide you, or your Designee and/or Provider with Our written decision (by mail or electronic means) and
the detailed reasons for Our decision including clinical rationale (if applicable) without releasing protected peer
review information, and references to any specific Plan provisions on which Our decision was based or a written
statement that insufficient information to reach a determination was presented or available as follows:

Requests for service (Precertification): Within 15 days of Our receipt of the Grievance.
Coverage for services rendered (Retrospective): Within 30 days of Our receipt of the Grievance.
Expedited Grievance (Urgent Care): Within 48 hours of receipt of all necessary information or 72 hours
from receipt of the Grievance, whichever is shorter.
Administrative matters concerning Our Network Providers: Within 45 days of Our receipt of all necessary
information.

If We render an Adverse Determination, We will include information on how to file an Appeal (Second-Level
Review) and how you can request, free of charge, reasonable access to, and copies of: documents,
records, and other information relevant to your issue.

Appeals (Second-Level Review)

If you are dissatisfied with the First-Level Grievance decision, you or your Designee may submit
an Appeal (request for a Second-Level Review). If an Appeal is clinical in nature, the review will
include a licensed, certified or registered individual who did not review your First-Level
Grievance. If the Appeal is administrative in nature, individuals of a higher level than those
who reviewed the Grievance will resolve the Appeal.

To initiate an Appeal, You or your Designee must write to Us at:

Oxford Health Plans, Grievance & Appeal Review Board, 48 Monroe Turnpike, Trumbull, CT 06611

You or your Designee have 60 business days from the date you received notice of Our Grievance decision to file an
Appeal. Unless We have already issued a written determination, We will provide written acknowledgment of the
receipt of your Appeal within 15 business days. The acknowledgment will include the name, address and phone
number of the individual designated to review your Appeal and what additional information, if any, must be
provided for Us to render a decision.

Additionally, you or your Designee must submit any documentation/information already requested by Us (if not
previously submitted) and any additional information you would like to submit in support of the Appeal. You may
send written comments, documents, records or other information regarding the claim. At the time of Our review,
We will review all available comments, documentation and information.

After consideration of all available information, We will make a determination in the following timeframes:

Administrative matters concerning Our Network Providers: Within 30 days of Our receipt of all necessary
information.
A request for Urgent Care (Expedited): Within 2 business days of Our receipt of all necessary information
when a delay would significantly increase the risk to your health.

This will be Our final position. You will be provided with a written or electronic determination notice containing the
detailed reasons for Our decision including clinical rationale (if applicable), and references to any specific Plan
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provisions on which Our decision was based. We will also include information on how you can request, free of
charge, reasonable access to, and copies of: documents, records, and other information relevant to your claim.

Part 3 Complaint Procedure

The Complaint Procedure is a mechanism used to provide you or your Designee with a method for submitting
Complaints to Us. A Complaint is an expression of dissatisfaction with any aspect of Our or a Network Providers
business operations, activities or behavior regardless of whether any remedial action is required. Types of
Complaints concerning Our operations include Complaints about Customer Care, personnel, balance billing and
complaints about privacy and HIPAA protected health information. Complaints about Network Providers may
include quality issues, access to care and communication.

Please Note: Dissatisfaction with Referral, benefit and Medical Necessity determinations are not considered
Complaints. Please refer to Part 1 of this section for information on the UR Appeal process and Part 2 of this
section for information on the Grievance and Appeal Procedure for benefit, Network and administrative Issues.

Our Complaint Procedure provides for either one level of internal review by Us or, if an Appeal is available, two
levels of internal review by Us. If you would like to file a formal Grievance regarding quality of care, you must use
the Grievance procedures described in Part 2 of this section.

All Complaints must be filed with Us either verbally or in writing not later than 180 days from the date you became
aware of the issue that initiated the Complaint. All requests to expedite the Complaint process must be made within
45 days from when the condition necessitating the need for an expedited Complaint arose, after which you may still
submit a non-expedited Complaint within the timeframes described in this paragraph.

Verbal complaints:

Verbal complaints must be made by calling the telephone number listed on the back of your Oxford identification
card. At the time of the call, you or your Designee must identify who is calling and indicate that you wish to file a
Complaint. You must provide the specific nature of your Complaint and may be asked to provide other relevant
information. We will attempt to resolve your Complaint at the time of the call. If a Complaint can be resolved on
the phone, no further follow-up will be provided. An electronic record will be made of any verbal communication.
To receive a written response to a Complaint, you or your Designee must submit the complaint in writing to
Oxfords Correspondence Department.

Written Complaints:

You or your Designee may also write to Us at the following addresses:

Complaints Regarding Individual Providers and Facilities: Oxford Health Plans, Quality Care/Service
Department, P.O. Box 400046, San Antonio, TX 78229

Complaints Regarding Dental Providers: Oxford Health Plans, Dental Department, 48 Monroe Turnpike,
Trumbull, CT 06611

Complaints Regarding Our operations: Oxford Health Plans, Correspondence Department, P.O. Box 29135, Hot
Springs, AR 71903

Complaints about PHI: Oxford Health Plans, Correspondence Department, P.O. Box 29135, Hot Springs, AR
71903

You or your Designee must submit the specific nature of your Complaint and any other relevant comments and
documentation/information you would like to submit in support of your Complaint. We will review all comments,
documentation and information available at the time of Our review.

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We will log and investigate the Complaint and provide a response verbally or in writing within 45 days of receipt of
the information necessary to resolve the Complaint. Complaints involving clinically urgent matters will be resolved
in a shorter timeframe.

There are some complaints that may not be resolved immediately or for which We may not be able to notify you or
your Designee of the resolution. For these types of cases, at a minimum, We will notify you or your Designee that
the Complaint was received and investigated.

If We have already responded to a complaint in writing, We will not respond to follow-up communications
regarding the complaint.

If you remain dissatisfied with the outcome of your Complaint, you may have the right to file an Appeal. An Appeal
is a request to change a previous decision made by Us. Appeal rights are available for those Complaints where an
Adverse Determination is made. The formal Appeal process provides a method for addressing any Adverse
Determination made by Us, including the outcome of a Complaint, if appropriate. For those Complaints where
Appeal rights are available, We will inform the you or your Designee of your right to Appeal with the initial
notification of the decision.

For example, if We have decided that you may not change your Primary Care Physician (PCP) when you want to do
so, it is an adverse benefit determination and would be subject to Appeal. However, if you complain that your PCP
or an Oxford Customer Care Associate was rude, there is no Adverse Determination to Appeal, even though We will
follow-up on the Complaint.

For instructions on how to initiate an Appeal of a Complaint for which an Adverse Determination has been rendered,
please refer to the Appeal (Second-Level) Review process in Part 2 of this section. Please note, you cannot waive
the Appeal Second Level Review and request an External Review.

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ERISA INFORMATION
Government, church groups and certain association groups are not subject to ERISA and therefore this section may
not apply. Please contact your employer for verification of whether this section applies to you.

General Information

Under the Employee Retirement Income Security Act of 1974 (ERISA), the Summary Plan Description (SPD) is the
primary vehicle for informing participants about their rights and benefits under the employee benefit plans in which
they participate. The Certificate of Coverage is not your SPD. Oxford, as the insurer, provides a Certificate of
Coverage to you identifying specific benefit and administrative components of your Plan.

The Plan Administrator (generally the Plan Sponsor) is responsible for the publication and distribution of the SPD.
Oxford is not the Plan Administrator or the Plan Sponsor. Generally the Plan Administrator or Plan Sponsor is your
employer.

Statement of ERISA Rights

The following statement of ERISA rights is required by Federal law and regulations.

If your group is subject to ERISA, you are entitled to certain rights and protections. Under ERISA you are entitled
to:

Receive Information about Your Plan and Benefits

Examine, without charge, at the Plan Administrators office, all documents governing the Plan, including
insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500
Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of
the Pensions and Welfare Benefit Administration.

Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the
Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual
report (Form 5500 Series) and updated summary plan description. The Plan Administrator may make a
reasonable charge for the copies.

Receive a summary of the Plans annual financial report. The Plan Administrator is required by law to
furnish each participant with a copy of this summary annual report.

Continue Group Health Plan Coverage

Continue health care coverage for yourself, your spouse or your Dependents if there is a loss of coverage
under the Plan as a result of a qualifying event. You or your Dependents may have to pay for such
coverage. Review your Summary Plan Description and the documents governing the Plan on the rules
governing your COBRA continuation coverage rights.

A reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group
health plan, if you have creditable coverage from another plan. You should be provided a certificate of
creditable coverage, free of charge, from your group health plan or health insurance carrier when you lose
coverage under the Plan, when you become entitled to elect COBRA continuation coverage, when your
COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24
months after losing coverage. Without evidence of creditable coverage, you may be subject to a
Preexisting Condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in
your coverage.
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Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your Plan, called
fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other Plan
participants and beneficiaries. No one, including your employer, or any other person, may fire you or
otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or
exercising your rights under ERISA.

Enforce Your Rights

If your claim for a benefit under the Plan is denied or ignored, in whole or in part, you have a right to know
why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any
denial, all within certain time schedules. Please refer to the Grievances and Appeals Section of this
Handbook for specific information.

Under ERISA, there are steps you can take to enforce your rights. For instance, if you request a copy of
Plan documents or the latest annual report from the Plan Administrator and do not receive them within 30
days, you may file suit in federal court. In such a case, the court may require the Plan Administrator to
provide the materials and pay up to $110 a day until you receive them, unless the materials were not sent
because of reasons beyond the control of the Administrator.

If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or
federal court. In addition, if you disagree with the Plans decision or lack thereof concerning the qualified
status of a domestic relations order or a medical child support order, you may file suit in federal court. If it
should happen that Plan fiduciaries misuse the Plans money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a
federal court. The court will decide who should pay court costs and legal fees. If your suit is successful,
the court may order the person you have sued to pay the costs and fees. If you lose, the court may order
you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with Your Questions

If you have any questions about your Plan, you should contact the Plan Administrator. If you have any
question about this statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Pension and Welfare
Benefits Administration, U.S. Department of Labor, listed in your telephone directory or:
Division of Technical Assistance and Inquiries
Pension and Welfare Benefits Administration
U.S. Department of Labor
200 Constitution Avenue N.W., Washington, D.C. 20210.

You may also obtain certain publications about your rights and responsibilities under ERISA by calling the
publications hotline of the Pension and Welfare Benefits Administration at 1-866-444-3272 or by logging
onto their website at www.dol.gov/ebsa/publications.
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The amount of Copayments,
Deductibles and Coinsurance
vary by Plan design. Please
check your Summary of Benefits
for the specific amounts that
apply to your plan.
Copayments, Coinsurance
and Deductibles accumulate
separately between In-
Network and Out-of-Network
benefits (if available).
How Covered Services are Reimbursed

This section is intended to educate you about how Covered Services are reimbursed and what your financial
responsibility will be for Covered Services so that your experience with Oxford is a positive one.

Overview

The total reimbursement made by Oxford will be dependent upon the fee schedule applicable to your health benefits
plan and your share of the costs. There may also be different levels of financial responsibility depending upon
whether Covered Services are obtained through your In-Network or Out-of-Network benefits (if available).
Generally, you will be responsible for paying a higher portion of your medical expenses when you obtain Out-of-
Network benefits. Please refer to your Summary of Benefits to determine if your Plan includes Out-of-Network
benefits.

Your share of the costs will depend upon your plan design and could include the following:

Copayments: The Copayment is a specific amount that you are required to pay directly to a Provider for In-Network
Covered Services at the time those Covered Services are rendered.

Deductibles: The amount that you must pay for Covered Services before reimbursement
under this Certificate is available. Please refer to the Claims Procedures Section of the
Certificate of Coverage for information on how your Deductible is calculated

Coinsurance: The percentage of the UCR Fee Schedule (as defined in the Definitions Section
of your Certificate of Coverage) for Covered Services that you are required to pay to a
Provider once any applicable Deductibles have been met.

Out-of-Pocket Maximum: Out-of-Pocket Maximums limit the amount of Coinsurance and Deductible you will pay
in any Plan Year. Once the Out-of-Pocket Maximum (shown in your Summary of Benefits) is reached for a Plan
Year, We pay 100% of the UCR Fee Schedule for Covered Services for the remainder of that year.

Amounts Greater Than UCR Fee Schedule: When receiving Covered Services from Providers who are not in Our
Network, you will be responsible for all amounts that exceed the UCR Fee Schedule. Please Note: Any amount you
pay for Out-of-Network charges that exceed the UCR Fee Schedule do not count toward the Out-of-Pocket
Maximum.

Oxford does not reimburse claims We have determined to be fraudulent.

In-Network Covered Services

In-Network benefits are provided through arrangements with Network Providers. We will reimburse the Network
Provider directly when you receive Covered Services.

Your Share of In-Network Costs: When you follow the In-Network guidelines and obtain
all required Referrals, where applicable, Covered Services will be subject to the Out-of-
Pocket Expenses set forth in your Summary of Benefits. When receiving Medically
Necessary Covered Services from a Network Provider, you will only be obligated to
reimburse the applicable Out-of-Pocket Expenses listed in your Summary of Benefits. Any
services you receive from Non-Network Providers will not be Covered unless your plan
includes Out-of-Network coverage. Please refer to your Summary of Benefits to determine if
you have Out-of-Network Coverage.

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31

Overview of Network Reimbursement Methodologies:

Physicians: More than 90% of Our Network Physicians are reimbursed on a discounted fee-for-service basis. The
fee schedules are based upon a combination of the following factors:

Information obtained from discounted Ingenix, Inc. Prevailing Healthcare Charges System (PHCS)
(formerly the Health Insurance Association of America (HIAA) database) based physician charge data and
fees. The charge data and fees are calculated using a Resource Based Relative Value Scale (RBRVS)
Methodology with an Oxford specific conversion factor.

Fees are also adjusted by geographic region.

The fee schedules are periodically updated based upon Our analysis of prevailing charges of other managed
care organizations and products in the markets We serve.

These Network Physicians are not currently subject to any Incentive Agreements. In general, Withholds and
Bonuses are known as Incentive Agreements. Under such agreements, Providers are paid less (a percentage of
their fee is withheld) or paid more (in the form of a bonus), based on a combination of factors that may include:
Member satisfaction, quality of care, control of costs, and their use of services.

Additionally, these Network Physicians are not Capitated. The terms Capitated or Capitation are used to describe
when a set dollar amount, per Member, is paid to the Provider regardless of the amount of services supplied.
Usually, the set amount is paid to the Provider each month and is based on the number of Members for whom the
Provider is responsible.

Less than 10% of Our Network Physicians are voluntarily aligned with other Network Physicians in loose-knit
groups or in more formal organizations that either:

accept compensation based upon a predetermined budget for the cost of Covered Services to Members, or
are subject to an Incentive Agreement (bonus) based on quality and utilization measurements.

Limited License Practitioners: We use the fee schedule that is used by Medicare to reimburse Limited License
Practitioners (non-Physician healthcare professionals). Network Limited License Practitioners are not subject to a
Withhold or any other Incentive Agreement. Our Network Limited License Practitioners are not Capitated.

Laboratory Services: We have negotiated a Capitation agreement with LabCorp to provide outpatient laboratory
tests for the majority of Our Members, with no Out-of-Pocket Expense to Our Members.

Hospitals and Other Facilities: Reimbursement to Network Facilities is made on a discounted fee-for-service basis
in accordance with individually negotiated agreements. We do not have Capitation agreements or Incentive
Agreements with any of Our Network Facilities.

Effect Of Network Reimbursement Policies: We have established all of the above-described reimbursement
methodologies for the dual purpose of:

ensuring the appropriate level of healthcare utilization while maintaining quality of care, and
controlling the cost of health services, including hospitalization.

We believe that the implementation of these reimbursement methodologies has produced the results they were
designed to accomplish (i.e., high quality and cost effective delivery of care). Through the application of Our
Quality Assurance protocols, We continuously monitor Our Providers to ensure that Our Members receive a high
standard of care.

New York Handbook

32

Please refer to your
Summary of Benefits to
determine if Out-of-Network
benefits are available.
Please refer to your Summary
of Benefits to determine the
level of reimbursement your
Group has purchased.
Out-of-Network Covered Services

If Out-of-Network benefits are available under your Plan, such benefits will be reimbursed
according to the UCR Fee Schedule applicable to your health plan, and the Deductible and
Coinsurance amounts shown in your Summary of Benefits.

The UCR Fee Schedule is a compilation of the maximum allowable fees for Covered Services,
supplies and drugs. The maximum allowable fee on the UCR Fee Schedule will be the lesser of:

the amount charged; or
the amount the Provider agrees to accept as reimbursement for the particular Covered Services; or
the amount that, in Our sole discretion, is the Usual, Customary and Reasonable (UCR) fee for particular
Covered Services.

The UCR Fee Schedule which applies to your Plan depends upon the level of reimbursement
your Group has purchased, (i.e., standard plan, high plan, very high plan, percentage of
Medicare fee schedule, etc.). We will update the UCR Fee Schedule from time to time, which
may result in an upward or downward adjustment for a particular fee.

How Out-of-Network Fee Schedules are Established: In evaluating and establishing a
particular UCR Fee Schedule, We consider data and guidelines (including re-bundling guidelines) compiled by

Centers for Medicare and Medicaid Services (CMS),
Ingenix, Inc., and
other sources recognized by the health insurance industry and federal government payers of health care
claims, as a basis for evaluating and establishing fees for Covered Services, supplies, and/or drugs.

When We use Ingenix fee data as the basis for a fee in the UCR Fee Schedule, we will use the Ingenix Prevailing
Healthcare Charges System (PHCS) data (formerly known as the HIAA database) or another comparable database if
the PHCS database no longer exists.

The UCR Fee Schedule for Covered injectible drugs (i.e., J-Code drugs) will be based upon a percentage of Average
Wholesale Price (AWP) or Average Sales Price (ASP). If your UCR Fee Schedule uses AWP data, We will use
Medicares methodology to select the AWP. Retail and mail order pharmacy benefits are not covered on an Out-of-
Network basis and take-home drugs will not be reimbursed when dispensed by your doctor, a hospital pharmacy or
any other Provider.

Normally, the data We will consider when compiling the UCR Fee Schedule for Covered Services will be based
upon the geographic location where the services are provided or, when outside of Our Service Area, will be based on
a locale that in Our discretion is comparable. Some data sources considered by Us do not report or collect data
based upon geographical location and when such data sources are considered and utilized by us to establish the UCR
Fee Schedule, the UCR fees will not be based on geographical data.

The data We choose to consider and the UCR fees we establish will be based upon the plans level of reimbursement
which is purchased by an employer for the benefit of the employers group plan, (i.e. a standard, high or very-high
plan).

We will implement policies and procedures as needed, to further describe the methodology We choose to use when
establishing the UCR Fee Schedule. Upon written request, We will provide any available additional information
about how We established the UCR fee schedule applicable to your plan. The UCR Fee Schedule for Covered
Services, supplies and/or drugs which We choose to establish for your product will be adjusted in accordance with
the methodology described in Our policies and procedures.

New York Handbook

33

For more information on the
following policies, please refer
to Our website:
Reimbursement
Methodology for
Comprehensive and
Component Codes
Modifiers
Distinct Procedural
Service (Modifier -59)
Multiple Surgical
Procedures (Modifier -
51)
Bilateral Procedures

Your Financial Responsibility for Out-Of-Network Services: In addition to any amounts you may be required to
contribute toward the Premium, you are responsible for any amounts above the UCR Fee Schedule and the
following:

Deductibles and Coinsurance: When you choose to use Non-Network Providers or In-Network Providers without
obtaining a Referral (if required), your portion of the medical expenses will in most instances include a Deductible
and Coinsurance.

Out-of-Pocket Maximum: Out-of-Pocket Maximums limit the amount of Coinsurance and Deductible you will pay
in any Plan Year. Once the Out-of-Pocket Maximum (shown in your Summary of Benefits) is reached for a Plan
Year, We pay 100% of the UCR Fee Schedule for Covered Services for the remainder of that year.

For example: A plan carries a $1000 Deductible plus Coinsurance of 20% and the Out-of-Pocket Maximum
for the plan is $2,000 for an individual Member. When the Member pays the $1000 Deductible and 20% of
the next $5,000 worth of Covered Services, the Member will have paid "out-of-pocket" $2000. Having
reached the maximum, We would reimburse the remaining Covered Services for that Plan Year at 100% of
the UCR Fee Schedule or the dollar limit in your Summary of Benefits without applying any additional
Coinsurance obligation.

You still are responsible to reimburse the Provider for any amounts he/she charges above the UCR Fee Schedule and
for any non-Covered Services.

For example: You have paid the necessary amount to meet your Deductible, however you have not yet
reached your Out-of-Pocket Maximum and your Plan requires a 20% Coinsurance for Covered Services
received Out-of-Network. Your Out-of-Network Provider charges $500 for a Covered Service. The UCR
Fee Schedule amount applicable to your plan for that Covered Service is $400. In this case, you will be
responsible for 20% of the $400 allowed by the UCR Fee Schedule ($80) in addition to the amount charged
in excess of the UCR Fee Schedule ($100). Your total out-of-pocket expense will be $180.

Certain Out-of-Network services are subject to a penalty when a required Precertification is not obtained. Any
Precertification penalties you pay do not accumulate towards your Out-of-Pocket Maximum. Additionally, if you
have reached your Out-of-Pocket Maximum, you will still be subject to the Precertification penalty for the benefits
received.

For example: A Member has reached her Out-of-Pocket Maximum and submits a claim for a surgical
procedure for which required a Precertification which was not obtained. The claim is for $1000 and the
UCR Fee Schedule amount is $1000. The penalty under the Members plan is 50%. After review for
Medical Necessity, Oxford reimburses $500 and the Member is responsible for the
penalty. If the Precertification had been obtained prior to receiving the services,
Oxford would have reimbursed $1000 for the surgery.

Fee Schedules for Comprehensive Services

Oxford will reimburse the comprehensive procedure code that fully describes the entire service
you receive, rather than the component, incidental or mutually exclusive procedure codes billed
by a provider. Thus, the reimbursement for the component, incidental or mutually exclusive
procedure codes is included within the Fee Schedule amount for the comprehensive procedure.
Oxford uses a re-bundling software package assembled by IntelliClaim to make these
determinations. There are a limited number of instances when Oxford will reimburse for the
component or incidental codes separately.

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34

following policies, please
refer to Our Website:
Physician Extender
Outpatient Mental
Health for Commercial
Members

Fee Schedules for Multiple Procedures

There may be times when two or more surgical procedures are performed during the same operating session. There
is a savings associated with performing multiple procedures during the same operating session, including the use of
one operating tray.

Oxfords Fee Schedules list the fees for the procedure as if each procedure were performed alone. When multiple
procedures are performed during the same operating session, the Fee for the primary procedure will be 100% of the
Fee Schedule amount and for all other surgical procedures (secondary procedures), the Secondary Fee Schedule
amount will be 50% of the Fee Schedule amount had the procedure been performed alone. We will consider the
procedure with the highest UCR Fee Schedule amount to be the primary procedure. All other procedures performed
during the operative session are multiple procedures. There are a limited number of instances when Oxford will
reimburse more than one procedure as the primary procedure.

Fee Schedules for Bilateral Procedures

Bilateral procedures (typically surgeries) are the same procedures performed on both the left and the right side of the
body (e.g., bunionectomy surgery on both feet) or the left and right members of paired organs (e.g., hernia). CMS
has determined that certain procedure codes identify bilateral procedures (e.g., a vision test is performed on both
eyes) while other procedures identify unilateral procedures that are performed on one side of the body. Oxford's Fee
Schedules generally apply to unilateral procedures, unless CMS has specifically identified the procedure code as
bilateral. Where CMS has identified the procedure as bilateral, it will be reimbursed in accordance with the Fee
Schedule for that service. When a unilateral procedure is performed bilaterally, Oxfords Bilateral Fee Schedule
will be one and one-half times (150% of) the unilateral allowance. There are some procedures that cannot be
performed bilaterally. If such a procedure is billed as a bilateral procedure, Oxford will correct the coding error and
process the claim in accordance with the applicable Fee Schedule.
Fee Schedules For Non-Physician Healthcare Professionals

The Fee Schedules have been established based upon the principle that the services you receive will be supplied by a
licensed Physician. Adjustments are made to the Fee Schedules when Covered Services are provided by non-
Physician healthcare professionals.

There may be times when certain Covered Services will be provided by medical personnel, other than a licensed
Physician. A Physician extender is specially trained and certified to provide basic medical services under the
supervision of a licensed Physician. Physician Extenders may order tests and make Referrals (if required) related to
the Members medical needs. Physician Extenders function as an agent of the Physician. Physician Extenders
include, but are not limited to, nurse practitioners, physician assistants, certified nurse midwives, certified registered
nurse anesthetists, registered nurse first assistants and clinical nurse specialists.

There may be times when Covered mental health services will be provided by a licensed mental health practitioner
who is not a medical doctor. In addition to psychiatrists who are medical doctors, psychologists who have a PhD or
PsyD, Social Workers and Advanced Practice Registered Nurses may perform certain services.

Our Reimbursement Policy provides reimbursement for such Physician Extenders, social workers
and psychologists as follows:

for nurse practitioner services, clinical nurse specialist services and physician assistant
services that are non-surgical,

85% of the Out-of-Network Reimbursement Amount or
In-Network contracted fee;
for services as an assistant surgeon performed by a nurse practitioner, clinical nurse
specialist, registered nurse first assistant, and physician assistant 14% of the Out-of-Network
Reimbursement Amount or In-Network contracted fee;
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35

following policies, please
refer to Our Website:
Global Surgical
Package
Modifier -25
Pro-rating Maternity
Claims
Technical Component
and Professional
Component (TC/PC)

for certified registered nurse anesthetist and anesthesia assistant services,

50% of Out-of-Network
Reimbursement Amount or In-Network contracted fee;
for certified nurse midwife services,

100% of the Out-of-Network Reimbursement Amount or In-Network
contracted fee;
for advanced practice registered nurse services, social worker services, psychologists services and advance
licensed professional counselor services for behavioral health,

85% of the Out-of-Network Reimbursement
Amount or In-Network contracted fee; and
Covered drugs (including vaccines, flu shots, antibiotics, etc.) and devices are reimbursed at 100% of the
Out-of-Network Reimbursement Amount or In-Network contracted fee when provided by Physician
Extenders.

Co-Surgeons or Assistant Surgeons

There may be times when it will be Medically Necessary for an additional surgeon to assist during a particular
surgical procedure or when there is no primary surgeon and two or more surgeons (co-surgeons) perform a particular
surgery. The Out-of-Network Reimbursement Amounts are calculated based on the principle that the services you
receive will be supplied by a single primary surgeon.

Our Reimbursement Policy makes adjustments to the Out-of-Network Reimbursement Amount or In-Network
contracted fee when Covered Services are provided by a surgeon other than the primary surgeon. Payments for
professional services to a surgeon other than the primary surgeon will be made as follows:

assistant surgeons at 14% of the Out-of-Network Reimbursement Amount or In-Network contracted fee for
that procedure, and
co-surgeons at 62.5% of the Out-of-Network Reimbursement Amount or In-Network contracted fee for
that procedure.

The percentage for team surgeries with more than two surgeons will be reviewed on an individual basis prior to the
surgery to determine the percentage of the Out-of-Network Reimbursement Amount or In-Network contracted fee
which is eligible for reimbursement to each surgeon.
.

Reimbursement for Global Periods

A global period for surgical procedures is a long-established concept under which a "single fee" is
billed and paid for all services furnished by a surgeon before, during and after (e.g., follow-up
visits) the procedure, regardless of where the service is performed (e.g., hospital, ambulatory
surgery center, physicians office). Oxford will reimburse a global fee for all surgical procedures
assigned a time frame by CMS in the Medicare Fee Schedule Data Base (MFSDB) which
indicates the number of days that make up the global timeframe. Any evaluation and
management procedures performed and certain supplies provided within the follow-up period will
not be reimbursed separately, as the payment for these services and supplies are included in the
reimbursement for the surgical procedure.

There are a limited number of instances when Oxford will reimburse for services and supplies provided during the
global period.

Fee Schedule For Maternity Claims: The global fee for routine maternity care, includes all services, including the
period of time prior to delivery that includes all office and hospital visits following the initial diagnosis of
pregnancy, delivery and postpartum services.

If during a pregnancy, you obtain services from a different Provider, the services may be prorated. If possible,
services are split into delivery/postpartum services and pre-delivery services. The billed amount is proportionately
distributed to each new prorated CPT code. Each trimester is calculated at 13.6% (.136) of the Fee Schedule and the
delivery/postpartum is calculated at 59.2% (.592) of the Fee Schedule.
New York Handbook

36

Splitting Global Fees Into Technical and Professional Components: There are certain types of services, such as
the taking and reading of an x-ray which include both physician services and the facility services. Oxfords Fee
Schedules list the global reimbursement for the service (professional services + technical services = global).

Some full service Providers will be reimbursed the global fee. There may be times when the physician services
otherwise known as the professional component, will be billed separately from the facility services otherwise known
as the technical component. The professional component or physician services would normally include the reading,
examination or interpretation of the specimen or procedure. The technical component would normally include
attaining the specimen, performing procedure, or taking an x-ray or other imaging procedure.

When the professional component and/or technical component services are billed separately, We will split the global
fee between the physician and the facility. The percentage of the global fee allocated to each component is
calculated based upon CMS guidelines. Our claims system is programmed to make this calculation automatically.

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37

Notification of Federal Legislation

The Newborns and Mothers Health Protection Act of 1996 (NMHPA)

NMHPA was signed into law on September 26, 1996, and applies to Plan years beginning on or after January 1,
1998. Key provisions of NMHPA are as follows:

Group health plans and health insurers generally may not, under Federal law, restrict benefits for any
hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law
generally does not prohibit the mothers or the newborns attending provider, after consulting with the
mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any
case, plans and issuers may not, under federal law, require that a Provider obtain authorization from the
plan or the insurance issuer for prescribing a length of stay not in excess of the above periods.

NMHPA does not prevent a group health plan, insurance company or HMO from imposing Deductible,
Coinsurance, or other cost-sharing measures are not greater than those imposed on any preceding portion of
the hospital stay.

Womens Health and Cancer Rights Act of 1998 (WHCRA)

WHCRA was signed into law on October 21, 1998, and applies to Plan years beginning on or after that date.
WHCRA provides that, in the case of a participant or beneficiary who is receiving benefits under a group health plan
in connection with a mastectomy and who elects breast reconstruction, coverage under the Plan will be provided in a
manner determined in consultation with the attending physician and that patient for:

Reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
Prostheses and treatment of physical complications at all stages of the mastectomy, including
lymphedemas.

Under WHCRA, coverage of breast reconstruction benefits may be subject only to deductibles and coinsurance
limitations consistent with those established for other benefits under the plan.
New York Handbook

38

Evaluating New Medical Technology

The following information is intended to help you understand Oxfords process for evaluating new medical
technologies. The results of the evaluation are incorporated into Our clinical policies and procedures.

New medical technology is defined as a newly approved drug or medication, a new surgical procedure, or new
medical equipment. Oxford continually assesses new medical technologies to make sure that Members have
appropriate access to the latest and most effective medical treatment available.

Oxfords Healthcare Services Department, led by experienced physicians representing multiple specialties, evaluates
new medical technology. The process begins with a review of the medical literature and other technical research.
The clinical staff also seeks opinions from leading physicians and specialists in the community who have knowledge
and expertise regarding how new medical technology will be used.

Once a thorough review of the available information has been conducted, Oxfords senior medical staff meets to
decide whether or not to cover the new medical technology. Once the policy regarding the new technology is
finalized, and implemented, Oxford notifies network physicians and other customers, as appropriate.
New York Handbook

39

Member Rights and Responsibilities

This explains your Rights and Responsibilities as an Oxford Member in terms of what you are entitled to (your
rights) from Oxford and Our Network Providers, as well as what you are responsible for in terms of your treatment
and your interactions with Oxford.

As a Member, you have the following rights:

1. The right to obtain complete and current information concerning a diagnosis, treatment, and prognosis from any
Network Provider in terms that you or your Designee can readily understand. If appropriate, this information
will be made available to another person acting on your behalf. You have the right to be given the name,
professional status, and function of any personnel delivering Covered Services to you.

The right to receive all information from a Network Provider necessary for you to give informed consent before
the start of any procedure or treatment.

The right to refuse treatment to the extent permitted by law. We and your Network Provider will make every
effort to arrange a professionally acceptable alternative treatment. However, if We and your Network Provider
believe no professionally acceptable alternative exists, We will not be responsible for the cost of further
treatment for that condition. You will be notified accordingly.

2. The right to be provided with accurate, relevant information about Us, Our services, policies, procedures,
grievances and appeals, Network Providers, and Members rights and responsibilities in an easily understood
manner and to make recommendations regarding Our Members rights and responsibilities policies.

3. The right to access quality healthcare services, provided in a professional manner that respects your dignity and
protects your privacy.

4. The right to privacy and confidentiality of your health records, except as otherwise provided by law or contract.
You have the right to all information contained in your medical records unless access is specifically restricted
by the attending Physician for medical reasons. Please refer to the privacy and confidentiality material
enclosed with the Certificate of Coverage for more information.

5. The right to initiate disenrollment from the Plan in accordance with Plan provisions.

6. The right to file a formal grievance or appeal if complaints or concerns arise about Our medical or
administrative services or policies.

7. The right to access Medically Necessary Covered Services without unnecessary delay, including Emergency
and Urgent Care Services 24 hours a day, seven days a week.

8. The right to be advised if any Network Providers participating in your care proposes to engage in or perform
human experimentation or research affecting your care or treatment. You or your Designee may, at any time,
refuse to participate in or to continue in any experimentation or research program to which you have previously
given informed consent.

9. The right to participate in decision-making regarding your healthcare. This includes the right to candid
discussions of appropriate or Medically Necessary treatment options for your conditions regardless of cost or
benefit coverage.

10. The right to create an Advance Directive. An Advance Directive is a written, signed document that provides
instructions for your care if you are unable to communicate your wishes directly. Depending on the state where
you reside or are receiving treatment, the most common forms of Advance Directives are Living Wills and
New York Handbook

40

Durable Powers of Attorney. These documents instruct your healthcare Providers how to proceed if you cannot
communicate with them.

If you decide to execute an Advance Directive you should notify all of your regular Providers and a copy of the
item should be placed in your medical files. In addition, you should have some way of notifying police and
emergency medical personnel that you have made an Advance Directive. For example you may want to keep a
card in your wallet or purse.

You are not required to make an Advance Directive. If you do decide to make one, please note that you are
free to amend or cancel it at any time.

11. The right to sign language interpreter services in accordance with applicable laws and regulations, when such
services are necessary to enable you as a person with special communication needs to communicate effectively
with your Provider.

Should you have any difficulty in arranging for such services, please contact Us. We can also arrange for TTY
services. To receive payment for said service(s), please have your provider mail Us an invoice from the
translation service.

As a Member, you have the following responsibilities:

1. To enter into this Plan with the intent of following the policies and procedures as outlined in this Handbook, the
Summary of Benefits, and the Certificate.

2. To take an active role in your healthcare through maintaining good relations with your PCP and other Providers
and following prescribed treatment guidelines.

3. To provide, to the extent possible, information that Providers and Our staff needs in order to care for you as a
Member.

4. To understand your health problems and to participate in developing mutually agreed-upon treatment goals to
the extent possible.

5. To use the Emergency Room only as described in the Certificate.

6. To notify Us of any change in name, address or any other important information.
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41

Information on the Web

By logging on to www.oxfordhealth.com you can:

Search for a participating Oxford Provider, hospital, healthcare facility or pharmacy.

Review your claims and Referral status, or find out about Oxfords medical and administrative
policies.

Review your Member Handbook and Summary of Benefits to learn about your Covered Services, Out-
of-Pocket Expenses, and benefit limitations.

Change your address and change your PCP.

Obtain forms for Claims, exercise facility reimbursement, and student verification.

If you have pharmacy coverage through Oxford, you can obtain forms for Prescription Drug
Reimbursement, Home Delivery (mail order), and view or request a copy of Oxfords Drug Formulary.

Request copies of Member materials including Provider Rosters, self-help materials or new
Identification Cards.

Visit the oxfordhealth Center, an online health and wellness resource center which allows you to
access up to date information on a myriad of healthcare topics.

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42

Information Available Upon Request

As an Oxford Member, We will provide you with the following information upon your request:

! Copies of your Certificate, Handbook, Summary of Benefits, applicable Riders or a Roster. The Roster is a
tool to assist you in locating Network Providers.

! Our Annual Report which contains: a list of the names, business addresses and official positions of Our
Board of Directors, officers, controlling persons, and owners;

! Our most recent annual certified financial statement that includes a balance sheet and a summary of
receipts and disbursements;

! A description of Our procedures for maintaining confidentiality of medical records and other enrollee
information;

! Information about our quality assurance program. For a description of this program please refer to the
attachment titled Information About Your Oxford Coverage.

! A copy of Our Medical Policy regarding a specific disease or course of treatment, an experimental or
investigational drug, medical device or treatment in clinical trials. You may also request written clinical
review criteria and other clinical information We may use during the Utilization Review process. Please
Note: Requests for Medical Policies must relate to a valid medical need.

! A listing of Our Network Providers who speak languages other than English.

! The information We provide to the state regarding Our consumer complaints as required by Section 210 of
the Insurance Law.

! A copy of Our Individual HMO Contract and Member Handbook or Personal Plan Contract.

! A copy of the application procedures and qualification requirements for Our Network Providers.

! Information about Our Network Provider affiliations with Network Hospitals.

! If you have pharmacy coverage through Oxford, a copy of Our drug formulary. You may also inquire if a
specific drug is Covered or excluded under your Prescription Drug benefit.

Additionally, please see the Section titled Information
on the Web for information that can be accessed by
using Our website, www.oxfordhealth.com.

New York Certificate
OHINY EPO 4/03 6632 NY Small Metro Liberty Oxford Exclusive 9.12


NY Small Liberty Oxford Exclusive Plan Metro

Certificate of Coverage
&
Member Handbook

OHINY EPO 4/03 2 6632 NY Small Metro Liberty Oxford Exclusive Plan 9.12
CERTIFICATE OF COVERAGE ("Certificate")
for
OXFORD HEALTH INSURANCE, INC.("Oxford")

Please read this entire Certificate carefully, including your Summary of Benefits which contains information specific to your Group. These
documents, and any attached riders, describe your rights and obligations and those of Oxford.

Under this Certificate, you engage Oxford to make arrangements through which medical and hospital services will be delivered in accordance
with the terms and conditions of this Certificate and in reliance upon the statements you made in your application for coverage. Oxford agrees
with the Group to provide the Covered Services set forth in this Certificate, as may be amended from time to time by Oxford or the Group's Board
of Directors or similar body. Please note:

This Certificate and any riders, schedules or attachments have been delivered in consideration of the Group's timely payment of Premiums.

No services are Covered under this Certificate in the absence of current payment of Premiums, subject to a 30-day Grace Period and the
terms and conditions of the Certificate.

No services are Covered under this Certificate unless your coverage is in force at the time you receive services.

In some instances a medical procedure may not be Covered or may require Precertification. It is your responsibility to understand the terms
and conditions in this Certificate.

This Certificate replaces any older Certificate issued to you which provided coverage under the Plan.

This Certificate is not in lieu of and does not affect any requirements for coverage by Workers' Compensation Insurance.

This Certificate is governed by the laws of the State of New York.

Please Note: Unless otherwise expressly indicated in this Certificate, coverage will cease upon the termination of this Certificate. Benefit
changes are effective on the renewal date of this Certificate. Benefits do not vest.

I mpor t ant Tel ephone Number s and Addr esses

CUSTOMER CARE 800-444-6222
MEDICAL EMERGENCIES AND URGENT CARE
MEDICAL MANAGEMENT COORDINATOR
(AFTER 5:00 P.M)

800-444-6222
800-201-4911
COMPLAINTS, GRIEVANCES AND UTILIZATION REVIEW APPEALS
(AFTER 5:00 P.M)

800-444-6222
800-201-4911

*Customer Care and claims representatives are available Monday through Friday, 8 a.m. to 6 p.m.

IMPORTANT ADDRESSES

CLAIMS

P.O. BOX 29130
Hot Springs, AR 71903-29130

APPEALS AND GRIEVANCES

Correspondence Department
P.O. BOX 29135
Hot Springs, AR 71903-29135

Grievance Review Board
48 Monroe Turnpike
Trumbull, CT 06611

Secretary of the Grievance Review Board
48 Monroe Turnpike
Trumbull, CT 06611

Clinical Appeals
48 Monroe Turnpike
Trumbull, CT 06611

Oxford Health Plans Internet Address
www.oxfordhealthplans.com

Mental Health/Substance Abuse Clinical Appeals
OptumHealth Behavioral Solutions
Attn: Appeals Department
1900 E. Golf Rd.
Suite 300
Schaumburg, IL 60173

Please note: You can request additional information about Oxford
and your coverage under this Certificate. Upon your written
request, We will provide information pertaining to: Our Provider
reimbursement methodologies, Our Quality Assurance program,
Our Utilization Review Department and Our individual products.

CUSTOMER CARE

Please feel free to contact Our Customer Care Department with
any questions, issues or concerns you may have. In addition, we
welcome your input and suggestions on how we can improve Our
administrative polices. You can reach one of Our representatives
Monday through Friday, from 8:00 to 6:00 at the number listed in
the front of the handbook. If you have a question and prefer to
speak in a language other than English, please call Our Customer
Care Department to make arrangements to speak with one of Our
translators. When the Member Service Associate answers your call
please say Spanish (or the language you require). The
Representative will place your call on hold while they make
arrangements with the appropriate translator. Do not hang-up!
With the help of the translator, the Representative will be able to
answer your questions

SPANISH

Si necesita ayuda y prefiere informacin en Espaol por favor
llame al 888-201-4133.Cuando nuestro representante conteste la
llamada diga Spanish, Please o pida el lenguaje que usted
necesite. Nuestro representante pondr su llamada en espera, no
cuelgue el telefono. Nuestro representante regresar a la lnea
muy pronto y tendr a su disposicin un traductor. Con la ayuda de
el traductor, nuestro representante podr contestar sus preguntas.

CHINESE

RUSSIAN

Get t i ng St ar t ed

At Oxford, We recognize that trying to understand your health care
coverage can be difficult. This document contains a detailed
description of your Plan. You should be familiar with all of the
Plan's terms and conditions. They determine what coverage you
have and what amounts We will pay.

We also understand that you may need care before you have the
time to read and understand this Certificate. To assist you, the
following summary may be helpful.

1. Primary, Preventive and Specialist Care

This product does not have a gatekeeper, usually known as a
Primary Care Physician. You may see any Network Provider for
Primary, Preventive or Specialist Care. You will never need a
referral from a Network Provider or from Us.

All you need to do to access care is make sure that the Provider
you are planning to visit is a Network Provider.

To find out if a Provider is contracted with Us you can:

check your Provider Roster;
call Customer Care; or
visit Our Website.

Please Note: While you may obtain Primary and Preventive Care
Services from any Network Provider, We encourage you to use
those Providers who specialize in this type or care and are the best
prepared to provide these services. We recommend that you obtain
Primary and Preventive Care Services of the following types of
Providers:

Family Practitioners
General Practitioners
Internists
Pediatricians
OB/GYNs (as well as nurse practitioners and nurse midwives)

When you use these Network Providers for such services:

We believe you are receiving the best level of care possible; and

You will be charged a smaller Copayment (visits to Specialist
require a higher Copayment than visits to the Providers listed
above).

Important: Using one of these Network Providers for such care
does not create a patient Primary Care Physician relationship.
You cannot select a PCP. The Network Providers accessed for
Primary and Preventive Care will not be responsible for
coordinating your care. While they may make recommendations
or suggest that you visit a Specialist, they will not provide
referrals.

You must decide when and how to access services throughout the
network; without referrals or anyone coordinating your care.
Therefore, it is your responsibility to be certain that you visit only
Network Providers. Except for Medical Emergencies, and
Precertified visits to Out-of-Network Providers, only services
provided by a Network Provider are Covered. If you obtain Covered
Services from a Non-Network Provider, you will be responsible for
the entire cost of the services.

2. Hospitalizations and Inpatient Facility
Services

If a Network Provider recommends Hospital or surgical services, he
or she will need to obtain authorization from Us before such
services can be performed. This process is referred to as
Precertification. Before entering the Hospital, you may want to
check with Customer Care to verify that the Hospital is a Network
Provider and that the services have been Precertified.

3. Emergencies and Urgent Care

If you have a Medical Emergency, you should obtain medical
assistance immediately or call 911. Emergency room care is not
subject to Our prior approval. However, only Medical
Emergencies, as defined in this Certificate, are Covered in an
emergency room. Therefore, if you are not certain that you need
to visit the emergency room, you can call Our Medical Management
Coordinators. They are available 24 hours a day, 7 days a week.
The Coordinator will direct you to the emergency room of a Hospital
or other appropriate facility.

For Urgent Care services, you must call Our Medical Management
Coordinators and follow the instructions you will be given. When
this procedure is followed, your Urgent Care will be Covered in full,
less any required Copayment. This coverage will be provided
regardless of where you are (in or out of the Service Area) when
the need for Covered Services occur.

4. Customer Care

All coverage is subject to the terms and conditions contained in
your Plan documents. You should understand your rights and
obligations before you obtain services. If you have questions,
Customer Care will be pleased to help you.

Customer Care would also like to hear your suggestions on how
We can improve. Your comments will be taken into consideration
when Our administrative policies are developed or revised. Please
feel free to write or call Customer Care. The Member Service
Representative who receives your comments and suggestions will
forward them to the appropriate Oxford committee for
consideration. We will also inform you of the committees response.

5. More Information About Oxford Health

As an Oxford Member, you automatically receive a Certificate, the
attachment Information About Your Oxford Coverage, a Summary

of Benefits and a Provider Roster. Please note, you can request
additional information about Oxford and your coverage under this
Certificate. Upon your written request, We will provide any or all of
the following information:

Our Annual Report which contains: a list of the names, business
addresses and official positions of Our Board of Directors, officers,
controlling persons, and owners; and Our most recent annual
certified financial statement which includes a balance sheet and a
summary of the receipts and disbursements;

The information that We provide the State regarding Our consumer
complaints as required by Section 210 of the Insurance Law;

A description of Our procedures for maintaining confidentiality of
Member information;

A copy of Our drug formulary. You may also inquire if a specific
drug is Covered or excluded under this Certificate.

A copy of Our Medical Policy regarding an experimental or
investigational drug, medical device or treatment in clinical trials;

A copy of Our Medical Policy regarding a specific disease or course
of treatment. You may also request how this information, and any
applicable Utilization Review guidelines, may be used during the
Utilization Review process. Please note: requests for Medical
Polices are limited to two per letter and must relate to a valid need
on your part to assess your coverage under this Certificate.

To obtain this information, please send Us a letter indicating the
information you require. Please address your letter to: Managed
Care Act, Oxford Health Plans, 48 Monroe Turnpike, Trumbull, CT.
06611

TABLE OF CONTENTS

Important Telephone Numbers and Addresses....................................................3

Getting Started ..........................................................................................................5

More Information About Oxford Health Plans............................................................5

Section I. How the Plan Works

Network Providers .....................................................................................................9
Precertification...........................................................................................................9
Second Opinions .......................................................................................................9
Medical Emergencies ................................................................................................9
Urgent Care.............................................................................................................10
Diagnostic Testing and Laboratory Services ...........................................................10

Section II. Provider Participation and Transitional Care

Provider Participation ..............................................................................................10
Transitional Care.....................................................................................................10
Patient/Provider Relationship ..................................................................................10
Provider Reimbursement and Quality Assurance....................................................11

Section III. Who Can Join?

Eligibility...................................................................................................................11
Applying for Coverage.............................................................................................12
Effective Date of Coverage......................................................................................13
An Increase or Reduction in Benefits ......................................................................13
Notice of Change in Status......................................................................................13

Section IV. Covered Services

Primary and Preventive Care ..................................................................................14
Specialty Care .........................................................................................................16
Hospital and Other Facility-Based Services ............................................................20
Chemical Abuse and Chemical Dependency ..........................................................21
Medical Emergencies ..............................................................................................21
Urgent Care.............................................................................................................22
Ambulance Services and Prehospital Emergency Services ....................................22
Reimbursement and Copayments...........................................................................22

Section V. Scope of Coverage, Exclusions and Limitations ............................22

Section VI. How Will the Plan Handle Any Questions or Problems?

Grievance Procedure...............................................................................................28
Expedited Grievance Procedure..............................................................................29
Utilization Review....................................................................................................30
Expedited Utilization Review Appeal .......................................................................31
External Appeal .......................................................................................................32

Section VII. Termination of Coverage

How Your Coverage May Terminate .......................................................................34
Effective Date of Termination..................................................................................34

Section VIII. What Happens If I Lose Coverage?

Termination or Loss of Eligibility: Coverage Options...............................................35
Cobra.......................................................................................................................35
State of New York Continuation ..............................................................................36
Extended Benefits ...................................................................................................38
Conversion Privilege................................................................................................38
Other Available Coverage:
Leave of Absence or Lay-off ...................................................................................39
Family and Medical Leave Act.................................................................................39

Section IX. What Happens If A Provider Bills Me?

Filing a Claim...........................................................................................................39
Payment Options.....................................................................................................39
Limitations ...............................................................................................................39
If You Receive a Bill From a Network Provider........................................................40
Claim Information ....................................................................................................40

Section X. Other Important Documents

Supplemental Coverage by Rider............................................................................40
Summary of Benefits...............................................................................................40
Living Wills and Advance Directives........................................................................40

Section XI. Member Rights and Responsibilities

What Are My Rights as a Member?.........................................................................40
What Are My Responsibilities?................................................................................41

Section XII. General Administrative Policies and Procedures

Medical Records: Confidentiality and Authorization to Examine .............................41
Coordination of Benefits (COB) ...............................................................................41
Effect of Coordination..............................................................................................43
Reimbursement and Subrogation............................................................................43
Medicare and Other Government Programs ...........................................................43

Section XIII. General Provisions .........................................................................44

Section XIV. Definitions .......................................................................................45

Section I.
How t he Pl an Wor k s

1. Network Providers

This product does not have a gatekeeper, usually know as a
Primary Care Physician. You may see any Network Provider for
Primary, Preventive or Specialist Care. You will never need a
referral from a Network Provider or from Us.

All you need to do to access care is make sure that the Provider
you are planning to visit is a Network Provider.

To find out if a Provider is contracted with Us you can:

check your Provider Roster;
call Customer Care; or
visit Our Website.

Please Note: While you may obtain Primary and Preventive Care
Services from any Network Provider, We encourage you to use
those Providers who specialize in this type or care and are the best
prepared to provide these services. We recommend that you obtain
Primary and Preventive Care Services of the following types of
Providers:

Family Practitioners
General Practitioners
Internists
Pediatricians
OB/GYNs (as well as nurse practitioners and nurse midwives)

When you use these Network Providers for such services:

We believe you are receiving the best level of care possible; and

You will be charged a smaller Copayment (visits to Specialist
require a higher Copayment than visits to the Providers listed
above).

Important: Using one of these Network Providers for such care
does not create a patient Primary Care Physician relationship.
You cannot select a PCP. The Network Providers accessed for
Primary and Preventive Care will not be responsible for
coordinating your care. While they may make recommendations or
suggest that you visit a Specialist, they will not provide referrals.
You must decide when and how to access services throughout the
network; without referrals or anyone coordinating your care.
Therefore, it is your responsibility to be certain that you visit
only Network Providers. Except for Medical Emergencies, and
Precertified visits to Out-of-Network Providers, only services
provided by a Network Provider are Covered. If you obtain Covered
Services from a Non-Network Provider, you will be responsible
for the entire cost of the services.

2. Precertification. All admissions to health care facilities
and certain diagnostic tests and therapeutic procedures must be
Precertified by Us before you are admitted or receive treatment. If
you are unsure whether a procedure requires Precertification,
please call Our Member Service Department.

Precertification starts with a call to Our Medical Management
Department by the Network Provider involved. One of Our
experienced Medical Management professionals examines the
case, consults with your Network Physician and discusses the
clinical findings. If all agree, the requested test, procedure or
admission is Precertified. This comprehensive evaluation insures
that the treatment you receive is appropriate for your needs and is
delivered in the most cost-effective setting.

Covered inpatient services are Precertified for a specific number of
days. If your Network Physician believes that a longer stay is
Medically Necessary, the extension must be Precertified in order
for it to be Covered.

Your Network Physician is responsible for obtaining any required
Precertification. However, we recommend that you call Customer
Care to ensure that your services have been Precertified.

Please remember: Any Precertification you receive will not be
valid if your coverage under the Plan terminates. This means that
Covered Services received after your coverage has terminated will
not be Covered even if they were Precertified (unless coverage is
being continued in accordance with the Extended Benefits section
of this Certificate).

3. Second Opinions. We reserve the right to require a
second opinion for any surgical procedure. At the time of
Precertification, you may be advised that a second opinion will be
required in order for the services to be Covered. If a second
opinion is required, We will refer you to a Network Provider for a
second opinion.

In the event that the first and second opinions differ, a third opinion
will be required. We will designate a new Network Provider. The
third opinion will determine whether or not the surgery is
Precertified. There will be no cost to you for the second or third
opinion.

You may also request a second opinion. Please see Section
Covered Services, Second Opinions, for a complete explanation.

4. Medical Emergencies. If you have a Medical
Emergency, you should obtain medical assistance immediately or
call 911. Emergency room care is not subject to Our prior approval.
However, only Medical Emergencies, as defined in this
Certificate, are Covered in an emergency room. Therefore,
before you seek treatment, you may want to be certain that this is
the most appropriate place to receive care. You can call Our
Medical Management Coordinators. They are available 24 hours a
day, 7 days a week. Your Coordinator will direct you to the
emergency room of a Hospital or other appropriate facility.

5. Urgent Care. If you need Urgent Care, you must call Our
Medical Management Coordinators and follow the instructions you
will be given. When this procedure is followed, your Urgent Care
will be Covered in full, less any required Copayment. This coverage
will be provided regardless of where you are (in or out of the
Service Area) when the need for Covered Services occur.

6. Diagnostic Testing and Laboratory
Services. If your Network Provider recommends laboratory
testing, remind him or her to use a Network Provider. In addition,
Covered X-rays or diagnostic procedures performed at Network
facilities will be Covered by Us without any required Copayment.
Unless you are Hospitalized, Hospitals are not Network Providers
for these tests.

IMPORTANT: Utilization Review. All services that you seek to
have Covered under this Certificate are subject to Utilization
Review. This means that Our Medical Management Department
reviews pertinent medical information in order to evaluate whether
or not the proposed service, the service currently being provided, or
the service that was provided is Medically Necessary and a
Covered Service under the Certificate. Utilization Review is also
required when We need to make a determination that a service is
or is not experimental or investigational. For more information
about Our Utilization Review Policies please see Information About
Your Oxford Coverage which is attached to this Certificate.

Section II.
Pr ovi der Par t i c i pat i on
and Tr ansi t i onal Car e

1. Provider Participation

We cannot promise that a specific provider, even though listed in
the Provider Roster, will be available. A Network Provider may end
his or her contract with Us, or decide not to accept additional
patients. If you have any questions about whether or not a
particular Provider is currently participating or accepting new
patients, please feel free to call Member Service and inquire.

Please note, if you are undergoing a course of treatment at the time
your Network Provider leaves the Network, you may be eligible for
Transitional Care as described below.

2. Transitional Care

Your Provider Leaves the Network: If you are undergoing a
course of treatment when your Provider leaves the Network, you
may be able to continue to receive Covered Services from the
former Network Provider. In such instances, you may receive
Covered Services for up to 120 days after you receive notification
from Us that the Provider is no longer in the Network.

Regarding pregnancy, if the Provider leaves the Network while you
are in your second trimester, you may receive Covered Services
through delivery and any post-partum care directly related to the
delivery.

However, Transitional Care is available only if the Provider agrees
to continue to accept as payment the negotiated fee that was in
effect just prior to the termination of Our relationship with the
Provider. Further, the Provider must agree to adhere to all of Our
Quality Assurance procedures as well as all other policies and
procedures required by Us regarding the delivery of Covered
Services. If the Provider agrees to these conditions, you will
receive these Covered Services as if they are being provided by a
Network Provider. You will only be responsible for any applicable
Copayments. Please note: If the Provider was terminated by Us
due to a quality of care issue, Transitional Care is not available.

New Members Currently Undergoing a Course of Treatment: If
you are undergoing a course of treatment with a non-Network
Provider at the time your coverage under this Certificate becomes
effective, you may be able to receive Covered Services from the
non-Network Provider for up to 60 days from the effective date of
your coverage under the Certificate. This coverage is available only
if the course of treatment is for a life-threatening disease/condition
or a degenerative and disabling disease/condition. Coverage is
limited to the disease/condition. Regarding pregnancy, if your
coverage becomes effective while you are in your second trimester,
you may receive Covered Services from your non-Network Provider
through delivery and any post-partum care directly related to the
delivery.

However, Transitional Care is available only if the Provider agrees
to accept as payment Our negotiated fees for such services.
Further, the Provider must agree to adhere to all of Our Quality
Assurance procedures as well as all other policies and procedures
required by Us regarding the delivery of Covered Services. If the
Provider agrees to these conditions, you will receive these Covered
Services as if they are being provided by a Network Provider. You
will only be responsible for any applicable Copayments.

In order to obtain Transitional Care, you or your Provider should
call Medical Management at 1-800-444-6222 and request this
coverage.

3. Patient/Provider Relationship

Network Providers are solely responsible for all health services that
you receive. They will use their best efforts to render all necessary
and appropriate professional services in a manner compatible with
your wishes. All services are, of course, subject to the Network
Provider's professional judgment. If you refuse to follow a
recommended treatment, and the Network Provider believes that
no professionally acceptable alternative exists, you will be so
advised. In such a case, subject to the second opinion process,
the Network Provider will not have any further responsibility to
provide care for the condition under treatment. You will need to
select another Network Provider to pursue treatment options.

4. Provider Reimbursement and Quality
Assurance

Reimbursement

We reimburse our Network Providers in a variety of ways. The
most common is a discount off the Providers usual fee. This
means the Provider agrees to accept less than what he or she
would usually be paid for that service. In return, the Providers
name appears in Our Provider Roster which gives the Provider an
opportunity to gain new patients from among our Membership. For
more information on other types of reimbursement methodologies,
please see Information About Your Oxford Coverage which is
attached to this Certificate.

Quality Assurance

We carefully select the Providers who deliver services to our
Members as Network Providers. This helps Us to insure that you
receive consistent, quality care.

For more information about Our Quality Assurance Program,
please see Information About Your Oxford Coverage which is
attached to this Certificate.

Section III.
Who Can J oi n?

1. Eligibility

A. The Subscriber. To be eligible to enroll as a Subscriber, you
must be:

1. A full-time employee of the Group (or part-time employee or
retiree if this coverage was purchased by the Group);and

2. Entitled on his or her own behalf (in accordance with standard
Group policy, including satisfaction of any standard probationary or
waiting period established by Group and agreed to by Us), to
participate in the medical and Hospital benefits arranged by the
Group.

B. Dependents. To be eligible to enroll as a Covered Dependent,
a person must be: listed on the Enrollment Form completed by the
Subscriber; meet all Dependent eligibility criteria established by the
Group; and be either:

1. The Subscriber's lawful spouse; or

2. Any unmarried child who is either a step-child, legally adopted
child or proposed adoptive child (who is physically placed in
Subscriber's home), or a natural child of either the Subscriber or
the Subscriber's spouse. In addition, a child for whom Subscriber
or Subscriber's spouse is a court appointed legal guardian is
eligible for coverage as a Covered Dependent provided proof of
such guardianship is submitted with the Dependent's Enrollment
Form. The child must also be dependent upon the Subscriber for
support as defined by the United States Internal Revenue Code
and federal regulations.

Any such Dependent child must be:

i. under age 9 unless otherwise specified in the Summary of
Benefits, or

ii. between 19 and 23 years of age unless otherwise specified in
the Summary of Benefits, provided the child is a full-time student
in an accredited educational institution. We will require
satisfactory proof of such full-time student status. Such proof must
be provided within 30 days of Our request. Important: Residency
in the Service Area is not required. However, coverage outside the
Service Area is limited to Medical Emergencies and Urgent Care.
Preventive, Primary and Specialty Care is not Covered outside of
the Service Area. If a student takes Prescription Drugs on a
maintenance or routine basis, they must be filled at a Network
Pharmacy (coverage of Prescription Drugs is available only if the
Group has purchased Outpatient Prescription Drug coverage.
Please check the Supplemental Coverage section of Covered
Services to see if you have this coverage.

Student Medical Leave: A full-time student as described above
may continue coverage under the Plan for up to 12 months while
on medical leave and not attending classes. To be eligible for such
coverage, a students attending physician must certify, in writing,
the medical reason why the leave from school is Medically
Necessary. The letter from the physician must be sent to Us. The
students attending physician must be licensed to practice in the
State of New York. However, this provision does not require Us to
continue coverage beyond the age at which coverage would
otherwise terminate (the full-time student limiting age as shown in
the Summary of Benefits). The Premium charged for this coverage
will remain the same as when the student was enrolled in school; or

iii. a child, irrespective of age, who is or becomes and continues to
be both: (1) incapable of self-sustaining employment by reason of
mental retardation, mental illness, developmental disability or
physical handicap, which condition arose prior to attaining the age
when Dependent coverage for such individual would otherwise
terminate; and (2) chiefly dependent upon the Subscriber for
economic support and maintenance.

If the child becomes incapacitated while Covered under the Plan,
the Subscriber must provide Us with proof of such incapacity and
dependency within 31 days of the date Dependent coverage would
otherwise terminate.

For any such child, We will subsequently require proof of continued
incapacity. Such proof will be required annually after the initial two-
year period following the child's becoming eligible by reason of this
provision. Our determination of eligibility will be conclusive; or a
newborn child of a Member, including a newly born adopted child.

Please Note: This Plan will not Cover an individual as both a
Subscriber and a Dependent.

Any employee or Dependent who is eligible for Medicare is not
eligible for coverage under this Certificate unless he or she is
eligible for coverage in accordance with the conditions stated in the
Medicare and Other Government Programs section of this
Certificate.

2. Applying for Coverage

Applying for coverage is easy. Fill out an Enrollment Form and a
Health Coverage History Form, and submit them, it to your
employers Employee Benefits Department. The form should list
each eligible Dependent that you would like to have Covered.
Include all requested information. Please remember to sign the
forms before submitting them. You and your eligible Dependents
may enroll only at the times and under the conditions described
below.

Important: If you are continuing coverage under State
Continuation or COBRA, you may need to submit the Enrollment
Form and the Premium directly to Us. Please check with your
employer or Customer Care for further information.

You may apply for coverage as follows:

A. Group Open Enrollment Period. A Group Open Enrollment
Period will be held at least annually. At this time, eligible
employees and eligible Dependents may enroll as Members under
this Certificate. No evidence of good health or insurability will be
required.

B. Newly Eligible Employee. A new employee hired by the
Group, after the Group Open Enrollment Period, may apply for
coverage for himself or herself and eligible Dependents, within 31
days of becoming eligible, subject to the Group's eligibility
requirements. No evidence of good health or insurability will be
required.

C. Newly Eligible Dependents. Any person who becomes a
Dependent may be enrolled by submitting an Enrollment Form
within 31 days of becoming a Dependent. Dependents who are
being enrolled pursuant to a court order must enroll within 60 days
of the date of the court order. No evidence of good health
or insurability will be required. This provision also applies to
adopted and prospective adopted children (except for newborns as
discussed below). In order for such child to be enrolled, the
Subscriber must be legally obligated for such child's financial
support and the child must be physical placed (in residence) in the
Subscribers home.

D. Newborns and Newly Born Adopted Children. A newborn
child of the Subscriber or Subscriber's spouse will be Covered from
the date of birth only if the Subscriber completes and submits an
Addition, Termination, Change Form specifically adding the
newborn child as well as submits any applicable Premium to the

Group within 31 days following the birth. This provision also applies
to newly born adopted children if the Subscriber takes physical
custody of the child upon its release from the Hospital and files a
petition pursuant to section 115-c of the domestic relations law
within 30 days of birth, and provided no notice of revocation has
been filed and consent for the adoption has not been revoked.

Please note newborns and newly born adopted children who are
not enrolled during this 31-day period may only be enrolled during
the next Open Enrollment or pursuant to a Special Enrollment
Period (or 125 Plan provision) as described below.

IMPORTANT: Even if the Subscriber is already paying the
maximum Premium (Family Rate), an Addition, Termination,
Change Form is still necessary. We must have knowledge of the
childs presence on the Plan in order to produce an accurate
HIPAA Certificate of Prior Coverage. You will need (and are entitled
to) such certificate if your coverage ends under this Plan.

A HIPAA (Health Insurance Portability and Accountability Act)
Certificate is generated for all Members when coverage under the
Plan ends. It documents how long each Member was Covered
under the Plan. If you seek to obtain coverage under another
groups plan, the group or the groups carrier may request this
form. If you or your dependent has a preexisting condition, the new
carrier must credit the amount of time (time you were covered)
shown on your HIPAA Certificate against the length of time that is
applicable to their preexisting conditions limitation.

Further, enrolling your child will enable Us to identify your child as a
Member. When claims are submitted for your child, your child will
appear as a Member in Our system and We will be able to process
the claims.

E. Section 125 Plans. If the Group has established a plan in
accordance with Section 125 of the U.S. Internal Revenue Code,
eligible persons will be permitted to enroll without submitting an
evidence of good health or insurability if the enrollment is the result
of a "change in family circumstance," as defined by the Group's
plan and Section 125.

F. Special Enrollment Periods

1. Change in Family Circumstance: Subscribers who previously
declined coverage under any of the Groups plans may join off-
cycle when they gain a dependent either through marriage, birth or
adoption. The Subscriber and the new dependent(s) must enroll
within 30 days of the event (the marriage, birth or adoption).
Existing eligible dependents that had previously declined coverage
may also enroll at this time.

2. Loss of Other Coverage: If all of the following conditions are
met, an individual may be enrolled before the next open enrollment:

the employee or dependent was covered under another group
health plan or other health insurance at the time that coverage
under this Certificate was initially available; and

the employee stated in writing this was the reason for rejecting
coverage under this Certificate; and

The previous coverage has ended because of any of the following:
it was COBRA coverage that was exhausted; the individual lost
coverage due to a loss of eligibility (legal separation, divorce,
death, termination of employment or a reduction in work hours); or
the employer contribution toward such coverage was terminated.

If all these conditions are met, the employee or dependent may
request enrollment if they otherwise meet the eligibility
requirements of this Certificate. The individual must enroll within
30 days of the termination of the previous coverage or employers
last contribution.

Individuals who do not meet these requirements may only be
enrolled at the next Group Open Enrollment Period.

In addition, no person is eligible to re-enroll if he or she has had
coverage from Us terminated for cause as described in the
termination provisions of this Certificate.

3. Effective Date of Coverage

Subject to all of the applicable terms and conditions of the
Agreement (including the payment of Premiums by Group and Our
receipt of completed Enrollment Forms), coverage will become
effective as follows:

A. Initial Enrollment (During the initial Group Open Enrollment
Period). Coverage is effective on either the first day of the next
calendar month following the date of the Group Open Enrollment
Period or the effective date of the Agreement. Please read your
Summary of Benefits to determine which is applicable.

B. Newly Eligible Employee (Application within 31 days of
becoming eligible). Coverage is effective on either the first day of
the next calendar month following the date on which We receive
the completed application or as of the date the employee became
eligible. Please read your Summary of Benefits to determine which
is applicable.

C. Newly Eligible Dependents (Application within 31 days of
becoming eligible). Coverage is effective on either the first day of
the next calendar month following the date on which We receive
the completed application or as of the date the dependent became
eligible. Please read your Summary of Benefits to determine which
is applicable. Coverage is effective at birth for newborns and newly
born adopted children subject to the enrollment requirements as
described above.

D. Group Open Enrollment Period. Coverage will be effective on
either the first day of the next calendar month following the date of
the Group Open Enrollment Period or the renewal date of the
Agreement. Please read your Summary of Benefits to determine
which is applicable.

E. Special Enrollment Periods. Coverage will be effective the
first day of the first calendar month beginning after the date the
completed request for enrollment is received.

4. An Increase or Reduction in Benefits

If for any reason your benefits must increase or decrease (because
of a change in classification, earnings, etc.), your benefits will be
adjusted accordingly. Any such change will be effective as of the
date of the event that necessitated the change.

5. Notice of Change in Status

It is your responsibility to notify Us and your employer of any
changes which will affect your eligibility, or that of your
Dependents, for Covered Services under this Certificate. This
becomes very important should you or any of your Covered
Dependents require a HIPAA Certificate of Prior Coverage.

Section IV.
Cover ed Ser vi c es

You will receive Covered Services in accordance with the terms
and conditions of this Certificate only when the Covered Service
is:

Medically Necessary; and

Provided by a Network Provider or an appropriately licensed
Non-Network Provider for the treatment of a Medical
Emergency or Urgent Care situation (as described below).

Not excluded under this Certificate;

Not in excess of the benefit limitations described in this
Certificate or your Summary of Benefits; and

Received while your coverage is in force.

Important: We reserve the right to provide benefits in the manner
We determine to be the most cost effective. Further, based on Our
Medical Policies, We reserve the right to provide benefits in the
manner, and to the extent, We believe is Medically Necessary.
Please note, Our determinations of Medical Necessity may be
Appealed as described in the Utilization Review Appeal section of
this Certificate.

For Covered Services provided by a Network Provider, you will be
responsible only for the Copayment or Coinsurance shown in your
Summary of Benefits. Except for Emergency Care or Urgent Care
as described below, all Covered Services must be obtained
from Network Providers.

The only exception to this provision is when Our Medical Director
determines that Our Network does not have an appropriate
Network Provider who can deliver the care you need. In such
instances, Our Medical Director will approve a visit to a non-
Network Provider. All such exceptions will be made only when Our
Medical Director, after consulting with your Network Specialist, the
non-Network Provider and you, approves the treatment plan for the
delivery of these services. Covered Services rendered by this
Provider will be paid as if they were received In Network. You will
be responsible only for any applicable Copayment or Coinsurance.
You or your Network Specialist may call Medical Management
and initiate the request for this special exception.

1. Primary and Preventive Care

Primary Care consists of office visits, house calls and Hospital
visits provided by a Network Provider for consultations, diagnosis
and treatment of injury, disease and medical conditions.

Preventive Care consists of the following services, performed by
your Network Provider, for the purpose of promoting good health
and early detection of disease:

A. Well-Baby and Well-Child Care

Well-baby and well-child care which consist of routine physical
examinations including vision screenings (no refractions) and
hearing screenings, developmental assessment, anticipatory
guidance, and laboratory tests ordered at the time of the visit as
recommended by the American Academy of Pediatrics.
Immunizations and boosters as required by the State of New York
and the American Academy of Pediatrics are also Covered. This
benefit is provided to Members from birth through age 19 and is not
subject to Copayments, annual Deductibles or Coinsurance.

B. Adult Periodic Physical Examinations

We Cover adult periodic physical examinations according to the
schedule established by Our Regional Quality Management
Committees. Vision screenings do not include refractions;

C. Adult Immunizations

We Cover adult immunizations as recommended by the U.S.
Department of Health and Human Services. We may also follow the
recommendations of various professional organizations such as the
College of Family Practictioners;

D. Well-Woman Examinations

We Cover well-woman examinations which consists of a routine
gynecological examination, breast examination and Pap smear.
We will Cover two such examinations each Contract Year.
Mammograms are Covered as follows:

one baseline screening mammogram for women age 35
through 39;

one baseline screening mammogram annually for women age
40 and over.

If a woman of any age has a history of breast cancer or her mother
or sister has a history of breast cancer, We will Cover
mammograms as recommended by her Provider.

However, in no event will more than one Preventive Care
screening, per Contract Year, be Covered.

Diagnostic mammograms (mammograms that are performed in
connection with the treatment or follow-up of breast cancer) are
unlimited and are Covered whenever they are Medically
Necessary.

E. Family Planning

We Cover family planning services which consist of counseling on
use of contraceptives and related topics. The costs related to the
measuring and fitting of a contraceptive device are also Covered if
the service is performed during the annual well-woman
examination. The devises and other FDA approved implantable or
injectable birth control are Covered only when the Group has
purchased Outpatient Prescription Drug Coverage. We also Cover
vasectomies and tubal ligations.

Interruption of Pregnancy

Therapeutic abortions are Covered. Non-therapeutic abortions in
cases of rape, incest or fetal malformation are also Covered.
Elective abortions are Covered subject to the benefit limit listed in
the Summary of Benefits.

F. Screening for Prostrate Cancer

An annual standard diagnostic examination including, but not
limited to, a digital rectal examination and a prostate specific
antigen test for men age 50 and over who are asymptomatic and
for men age 40 and over with a family history of prostate cancer or
other prostate cancer risk factors.

Standard diagnostic testing including, but not limited to, a digital
rectal examination and a prostate specific antigen test at any age
for men having a prior history of prostate cancer.

G. Diabetic Supplies, Education and Self-Management

Diabetic Supplies, Education and Self-Management are Covered
as follows:

Supplies. The following equipment and related supplies will be
Covered for insulin dependent and non-insulin dependent
Members when Medically Necessary as determined by the
Member's Physician:

Acetone Reagent Strips
Acetone Reagent Tablets

Alcohol or Peroxide by the pint
Alcohol Wipes
All insulin preparations
Automatic Blood Lance Kit
Blood Glucose Kit
Blood Glucose Strips (Test or Reagent)
Blood Glucose Monitor with or without special features for visually
impaired, control solutions, and strips for home blood glucose
monitor
Cartridges for the visually impaired
Diabetes data management systems
Disposable insulin and pen cartridges
Drawing-up devices for the visually impaired
Equipment for use of the Pump
Glucose Acetone Reagent Strips
Glucose Reagent Strips
Glucose Reagent Tape
Injection aides
Injector (Busher) Automatic
Insulin
Insulin Cartridge Delivery
Insulin infusion devices
Insulin Pump
Lancets
Oral agents such as glucose tablets and gels, Glucagon for with
injection to increase blood glucose concentration
Oral anti-diabetic agents used to reduce blood sugar levels
Syringe with needle; sterile 1 cc box
Urine testing products for glucose and ketones

Additional items may also be Covered if the Member's Physician
determines they are Medically Necessary and prescribes them for
the Member. Such additional items must be Precertified by one of
Our Medical Case Managers and be in accordance with the
treatment plan developed by the Physician for the Member.

All items are subject to the Copayments, maximums and limitations
shown on the Summary of Benefits. If the Group has purchased
Outpatient Prescription Drug coverage from Us, many of these
items are also available through Our mail order program. When
purchased through Our mail order pharmacy, these items will be
delivered directly to your home or office. .

Self-Management and Education. Education on self-management
and nutrition is Covered when: diabetes is initially diagnosed; a
significant change in the Member's condition takes place; or the
Physician decides that a refresher course is necessary. It must be
provided:

In a Physician's office either by the Physician or his or her qualified
nurse during an office visit or in a group setting.

Upon a Physician's referral to the following non-physician, medical
educators (qualified health providers): certified diabetes nurse
educators; certified nutritionists; certified dietitians; and registered
dietitians.

Whenever possible, in a group setting, regardless of whether the
provider is a Physician or a qualified health provider. Education will
also be provided in the Member's home if the Member is
Homebound (as defined in Definitions).

Limitations

The items must be Medically Necessary as determined by the
Member's Physician and will only be provided in amounts that are
in accordance with the treatment plan developed by the Physician
for the Member.

All requests for insulin pumps must be reviewed by one of Our
Medical Case Managers and be approved by Our Medical Director.

Only basic models of blood glucose monitors will be Covered
unless the Member has special needs relating to poor vision or
blindness.

H. Health Education

Health education, information and health care literature which is
made available to Members through various programs provided
and developed by Us. These programs and information are
provided without cost to Members. Such programs include Our
Active Partners Program; Our Health Mother, Healthy Baby
Program; Our Better Breathing Program and Our Healthy Mind,
Health Body magazine.

I. Exercise Facility Reimbursement

Covered Benefits: We will partially reimburse the Subscriber and
the Subscribers Covered spouse (or Domestic Partner if the Group
has purchased this coverage) for certain exercise facility fees or
membership fees but only if such fees are paid to facilities which
maintain equipment and programs that promote cardiovascular
wellness.

How To Obtain Reimbursement: In order to obtain reimbursement,
You must submit a completed Reimbursement Form. For your
convenience, a Reimbursement Form has been included at the
back of this Certificate. Each time you visit the facility, a facility
representative must sign and date the form.

In order to be eligible for reimbursement, you must 1) be an active
member of the facility, and 2) complete the amount of visits shown
in your Summary of Benefits in a six-month period. At the end of
the six-month period, you must submit the Reimbursement Form to
Us along with a copy of your current facility bill which shows the
monthly cost for your membership. Once We receive the completed
Reimbursement Form and the bill, you will be reimbursed as
follows:

A Subscriber and the Subscribers spouse will be reimbursed the
lesser of the amount shown in the Summary of Benefits or the
actual cost of the membership per six-month period.

Limitations and Exclusions

1. Coverage is limited to facilities/programs that promote
cardiovascular wellness, as determined by Us. Memberships in
tennis clubs, country clubs, weight loss clinics or spas or any other
similar facilities will not be reimbursed.

2. Only the Subscriber and the Subscribers Covered spouse (or
Domestic Partner if the Group has purchased this coverage) are
eligible for this benefit. By Covered We mean that the spouse (or
Domestic Partner) must be enrolled in the Plan as an Oxford
Member. All other Covered Dependents are not eligible.

3. The Member seeking reimbursement must be an active member
of the facility.

4. Lifetime memberships are not eligible for reimbursement.

5. We will reimburse only those visits that were completed while
the person seeking reimbursement was a Member of the Plan. We
will not reimburse visits that occurred before coverage became
effective or after coverage terminates. No pro rata reimbursements
will be paid.

6. Reimbursement is limited to actual work-out visits. We will not
provide reimbursement for equipment, clothing, vitamins or other
services that may be offered by the facility (massages, yoga, etc.).

2. Specialty Care

Specialty Care consists of medical care and services, including
office visits, house calls, Hospital visits and consultations for the
diagnosis and treatment of disease or injury that are not ordinarily
treated by a general or family practitioner, internist or pediatrician.

MOST SPECIALTY CARE SERVICES REQUIRE
PRECERTIFICATION.

A. Surgical and Obstetrical Services

Network Physicians' services for surgical and obstetrical
procedures on an inpatient and outpatient basis, including the
services of the surgeon or specialist, assistant, and anesthetist or
anesthesiologist together with preoperative and post operative
care. Deliveries and related services that are performed by a
certified nurse midwife are also Covered.

Please remember, elective surgery and Hospital admissions,
including non-emergency maternity admissions, require
Precertification.

B. Maternity and Newborn Care

Maternity Care

Services and supplies for maternity care provided by a Network
Physician, Nurse Midwife, Nurse Practitioner, Hospital or Birthing
Center will be Covered for prenatal care (including one visit for

genetic testing), postnatal care, delivery and complications of
pregnancy. We provide a minimum inpatient stay of 48 hours
following a vaginal delivery and 96 hours following a cesarean
delivery for both the mother and the newly born child or children.
While in the hospital, maternity care also includes, at a minimum,
parent education, assistance and training in breast or bottle feeding
and the performance of any necessary maternal and newborn
clinical assessments.

The mother has the option to leave the hospital sooner than as
described above. If she decides to be discharged early, she will be
provided with one home visit. The home visit must be requested
by the mother within 48 hours of a vaginal birth or within 96 hours
of a cesarean birth. The visit will occur within 24 hours of the later
of: the mothers request; or her discharge from the hospital. This
visit is not subject to deductible Copayment or Coinsurance.
Additionally, the visit will not be deducted from the Home Health
Care visits Covered under the Certificate.

The home visit consists of a visit by a professional RN to provide
the following post delivery care: an assessment of the mother and
child, instruction on breastfeeding, cleaning and caring for child,
and any required blood tests ordered by the mothers or the childs
Network Provider.

Coverage for a routine delivery or maternity care outside of the
Service Area is limited. We define a routine delivery as a full-term
delivery that has occurred without any complications. If you
arrange to give birth at a facility outside of the Service Area,
and the delivery is routine, it will not be Covered. We will
assume that you have arranged to give birth at a facility outside of
the Service Area if you travel to the area of the facility near the time
of your delivery. In those instances where the non-Network facility
is near the Service Area, routine deliveries are not Covered if you
could safely have delivered in a Network Facility. Exceptions
will be made on a case by case basis if We determine that
circumstances beyond your control (such as a death in the family)
required you to be outside of the Service Area at the time of your
delivery.

Newborn Care

Care for newborns includes preventive health care services, routine
nursery care, and treatment of disease and injury. Treatment of
disease and injury includes treatment of prematurity, and medically
diagnosed congenital defects and birth abnormalities which cause
anatomical functional impairment. We also Cover, within the limits
of this Certificate, necessary transportation costs from the place of
birth to the nearest specialized treatment center. Please note, for
purposes of this Certificate a newborn child or newly born adopted
child means a child who is no older than 31 days old.

Please Note: In Network and Out-of-Network, routine and
preventive Newborn Care does not require Precertification.
However, services that generally require Precertification (such as
surgery) should be Precertified as described in this section,
Covered Services.

C. Infertility Treatment

Covered Benefits

Hospital care for the diagnosis and treatment of correctable
medical conditions otherwise Covered under the Certificate will not
be excluded solely because the medical condition results in
infertility. Additionally, this Certificate provides coverage for the
diagnosis and treatment (surgical and medical) of infertility when
such infertility is the result of malformation, disease, or physical
dysfunction. Such coverage is available as follows:

1. Basic Infertility Services: Basic Infertility Services will be
provided to a Member who, in Our opinion, is an appropriate
candidate for infertility treatment. In order to determine eligibility,
We will use guidelines established by the American College of
Obstetricians and Gynecologists, the American Society for
Reproductive Medicine, and the State of New York. However,
Members must be between the ages of 21 and 44 (inclusive) in
order to be considered a candidate for these services.

Basic Infertility Services consist of: initial evaluation, semen
analysis, laboratory evaluation, evaluation of ovulatory function,
postcotial test, endometrial biopsy, pelvic ultra sound,
hysterosalpingogram, sono-hystogram,testis biopsy, blood tests
and medically appropriate treatment of ovualtory dysfunction.
Additional, tests may be Covered if Our Medical Director
determines that they are Medically Necessary.

2. Comprehensive Infertility Services: Requires Precertification.
If the Basic Services do not result in increased fertility, Medical
Management may Precertify Comprehensive Infertility Services.
These services include: Ovulation induction and monitoring; pelvic
ultra sound; artificial insemination; hysteroscopy; laparoscopy; and
laparotomy.

Your Network Provider must obtain Precertification in order for
these services to be Covered.

Exclusions and Limitations

Coverage under this benefit is limited to Members age 21
through 44.

If your Certificate contains a Preexisting Conditions Limitation,
this benefit is subject to the terms and conditions of that
provision.

In vitro, GIFT and ZIFT procedures.

All services must be provided by Network Providers who are
qualified to provide such services in accordance with the
guidelines established and adopted by the American Society
for Reproductive Medicine.

Network Providers must provide all Covered Services.

Infertility drugs (including injectable drugs) such as Pergonal,
Metrodin, etc., are not Covered unless the Group has
purchased Outpatient Prescription Drug Supplemental
Coverage.

We will not Cover any infertility drugs administered in the
Network Providers office unless the Group has purchased
Outpatient Prescription Drug Supplemental Coverage.

Cost for an ovum donor or donor sperm.

Sperm storage costs.

Cryopreservation and storage of embryos.

Ovulation predictor kits.

Reversal of tubal ligations. Reversal of vasectomies.

Any infertility services if the male has undergone a vasectomy,
unless the vasectomy has been successfully reversed. Please
note, We do not Cover the reversal of vasectomies.

All costs for and relating to surrogate motherhood (maternity
services are Covered for Members acting as surrogate
mothers).

Experimental procedures and treatments (as determined by
the American College of Obstetricians and Gynecologists, the
American Society for Reproductive Medicine, and the State of
New York. Please remember, you have the right to an External
Appeal (as described in your Certificate) when We deny
experimental or investigational procedures.

Sex change procedures

Cloning

D. Allergy Testing and Treatment

Testing and evaluations to determine the existence of an allergy.
Routine allergy injections, including serums are Covered.

E. Rehabilitation Services

Rehabilitation therapy including physical therapy, speech therapy,
and occupational therapy, is Covered on an outpatient or inpatient
basis. Coverage on an outpatient basis is limited to the amount of
visits shown on the Summary of Benefits. Coverage on an
inpatient basis is limited to one consecutive 60-day period, per
condition, per lifetime in a Rehabilitation Facility. Admission to a
Rehabilitation Facility requires Precertification. For the purposes of
this benefit (both inpatient and outpatient), "per condition" means
the disease or injury causing the need for the therapy.

Speech and physical therapy are Covered only when:

such therapy is related to the treatment or diagnosis of a
Members physical illness or injury (in the case of a Dependent
child, this includes a medically diagnosed congenital defect);

it is Ordered by a Network Physician; and

the Member has been Hospitalized or has undergone surgery
for such illness or injury.

Covered Services must begin within six months of the later to
occur:

1. the date of the injury or illness that caused the need for the
therapy;

2. the date the Member is discharged from a Hospital where
surgical treatment was rendered; or

3. the date outpatient surgical care is rendered.

And in no event will the therapy continue beyond 365 days after
such event.

F. Reconstructive and Corrective Surgery

Reconstructive and corrective surgery is Covered only when:

1. it is performed to correct a congenital birth defect of a
Dependent child which has resulted in a functional defect; or

2. is incidental to surgery or follows surgery that was necessitated
by trauma, infection or disease of the involved part.

Breast reconstruction (including surgery on the healthy breast to
restore and achieve symmetry) or implanted breast prostheses are
also Covered.

Cosmetic surgery is not Covered. Please see the Exclusions
and Limitations, section of this Certificate.


G. Oral Surgery

General dental services are not Covered. The following limited
dental and oral surgical procedures are Covered in either an
inpatient or outpatient setting:

1. Oral surgical procedures for jaw bones or surrounding tissue
and dental services for the repair or replacement of sound natural
teeth that are required due to accidental injury. Replacement is
Covered only when repair is not possible (please see the
Exclusions and Limitations section of this Certificate). Dental
services must be obtained within 12 months of the injury.

2. Oral surgical procedures required for the correction of a non-
dental physiological condition which has resulted in a severe
functional impairment.

3. Removal of tumors and cysts requiring pathological examination
of the jaws, cheeks, lips, tongue, roof and floor of the mouth. Cysts
related to teeth are not Covered.

4. Surgical/nonsurgical medical procedures for TJM and
orthognathic surgery may be Covered if Precertified and approved
by Our Medical Director.


H. Laboratory Procedures and X-ray Examinations

X-ray and laboratory procedures, services and materials, including
diagnostic X-rays, X-ray therapy, fluoroscopy, electrocardiograms,
laboratory tests, and therapeutic radiology services are Covered
when performed on an outpatient basis.

Major diagnostic procedures require Precertification. It is
important that you do not seek the services of a laboratory or
imaging center without Precertification. If you do, you will be
responsible for the costs of such services. Please contact Our
Medical Management Coordinators before you obtain any of the
procedures listed in your Summary of Benefits.

I. Internal Prosthetic Devices

Surgically implanted prosthetic devices and special appliances will
be Covered if they improve or restore the function of an internal
body part which has been removed or damaged due to disease or
injury. This includes implanted breast prostheses. Coverage also
includes repair and replacement due to normal growth or normal
wear and tear.

Services under this section require Precertification.

J. External Prosthetic Devices

We Cover prosthetic devices (including wigs) that are worn
externally and that temporarily or permanently replace all or part of
an external body part that has been lost or damaged because of an
injury or disease. Wigs are Covered only when a Member has
severe hair loss due to injury or disease or as a side effect of the
treatment of a disease (e.g., chemotherapy). We do not Cover
wigs made from human hair unless the Member is allergic to all
synthetic wig materials.

For adults, We Cover the cost of only one prosthetic device per
lifetime. For children, the cost of replacements is also Covered but
only if the previous device has been outgrown. Purchase of the
device must be Precertified. Coverage is for standard equipment
only We do not otherwise Cover the cost of repairs or replacement.
In accordance with Our Medical Policy, external breast prostheses
following a mastectomy are also Covered.

K. Durable Medical Equipment and Braces


Durable Medical Equipment is equipment which is: 1) designed
and intended for repeated use; 2) primarily and customarily used to
serve a medical purpose; 3) generally not useful to a person in the
absence of disease or injury; and 4) is appropriate for use in the
home.

Coverage is for standard equipment only (please see the
Exclusions and Limitations section of this Certificate). All
maintenance and repairs that result from a Member's misuse are
the Member's responsibility. The decision to rent or purchase such
equipment will be made solely at Our discretion.

Braces

We Cover braces that are worn externally and that temporarily or
permanently assist all or part of an external body part function that
has been lost or damaged because of an injury, disease or defect.
Coverage is for standard equipment only. Replacements are
Covered when growth or a change in the Member's medical
condition make replacement Medically Necessary. We do not
otherwise Cover the cost of repairs or replacement (e.g., We do not
Cover repairs or replacement that is the result of misuse or abuse
by the Member).

Precertification Required: Precertification for the purchase of
Durable Medical Equipment or braces is required when the item will
cost $500 or more.

L. Medical Supplies

We Cover medical supplies that are required for the treatment of a
disease or injury which is Covered under this Certificate.
Maintenance supplies (e.g., ostomy supplies) are also Covered for
conditions Covered under this Certificate. All such supplies must
be Medically Necessary and in the appropriate amount for the
treatment or maintenance program in progress. Diabetic Supplies
are not Covered under this provision. Please see the Diabetic
Supplies, Education an Self-Management section of this Certificate
for a description of diabetic supply coverage.

Purchase of medical supplies does not require
Precertification.

M. Transplants

We Cover only those transplants that We determine to be non-
experimental and non-investigational. Covered transplants include
but are not limited to: kidney, corneal, liver, heart, and heart/lung
transplants; and bone marrow transplants for aplastic anemia,
leukemia, severe combined immunodeficiency disease and
Wiskott-Aldrich Syndrome.

All transplants must be prescribed by your Specialist(s) and
Precertified by Our Medical Director. Additionally, all transplants
must be performed at Hospitals that We have specifically approved
and designated to perform these procedures. Please see the
Exclusion and Limitations section of this Certificate for more
information regarding this benefit.

We will Cover the Hospital and medical expenses, including donor
search fees, of the recipient. We will Cover transplant services
required by a Member when the Member serves as an organ donor
only if the recipient is a Member. The medical expenses of a
non-Member acting as a donor for a Member are not Covered if the
non-Member's expenses will be covered under another health plan
or program.

We do not Cover travel expenses, lodging, meals or other
accommodations for donors or guests.

N. Home Health Care

We Cover care provided in your home by a Network Home Health
Service or Agency licensed by the appropriate state agency. The
care must be provided pursuant to your Network Physician's written
treatment plan and must be in lieu of Hospitalization or
confinement in a Skilled Nursing Facility. Home care includes
(i) part-time or intermittent nursing care by or under the supervision
of a Registered Professional Nurse (RN), (ii) part-time or
intermittent services of a home health aide, (iii) physical,
occupational, or speech therapy provided by the Home Health
Service or Agency, and (iv) medical supplies, drugs and
medications prescribed by a Network Physician, and laboratory
services by or on behalf of the Home Health Agency to the extent
such items would have been Covered during a hospitalization or
confinement in a Skilled Nursing Facility.

Home Health Care is limited to the amount of visits shown in your
Summary of Benefits. Each visit by a member of the Home Health
Care Agency or Service team is considered one visit. Each visit of
up to four hours by a home health aide is one visit.

Please note: Any rehabilitation services received under this
benefit will not reduce the amount of services available under
Rehabilitation Services above.

This benefit requires Precertification.

O. Chemotherapy

Chemotherapy is Covered on an inpatient basis in a Hospital or
Skilled Nursing Facility, through Home Health Care or on an
outpatient basis in an outpatient facility. Precertification is required.
Chemotherapy is also Covered when provided in a Network
Physicians office. When provided in the office, Precertification is
not required.

P. Second Opinions

There may be instances when you will disagree with a provider's
recommended course of treatment. In such cases, you may
request that We designate another Network Provider to render a
second opinion. If the first and second opinions do not agree, We
will designate another Network Provider to render a third opinion.
After completion of the second opinion process, We will Precertify
Covered Services supported by a majority of the Providers
reviewing your case. You must pay any Copayment for a second
opinion that you request.

Important: If the first opinion concerns a diagnosis of cancer
(either negative or positive) or treatment for cancer, you may obtain
a second opinion from a non-Network Provider on an In Network
basis.

Please note: Providers who render a second or third opinion
cannot perform the Precertified service. If We Precertify a service
that is recommended by the second (or second and third ) Provider,
you will be asked to use select another Network Provider to
perform the actual service.

We also may require a second opinion before We Precertify a
surgical procedure. In these instances, We will follow the
procedure as described in, How the Plan Works. There is no cost
to you when We request a second opinion.

Q. Chiropractic Services

We will Cover spinal subluxation and related services when
performed by a Network Doctor of Chiropractic (Chiropractor).
This includes assessment, manipulation and any modalities. This
benefit is unlimited. By unlimited We mean there is no dollar limit
or visit limit on spinal subluxation.

This benefit remains subject to Medical Necessity. Coverage
also remains subject to the Copayments, Coinsurance and
Deductible shown in your Summary of Benefits.

Any Medically Necessary laboratory tests will be Covered in
accordance with the terms and conditions of this Certificate.

3. Hospital and Other Facility Based Services

Please remember, in order to receive coverage for any facility
based Covered Service, the Covered Service must be
Precertified.

A. Hospital Services (Excluding Chemical Abuse and Chemical
Dependency)

Inpatient: Hospital Inpatient services for acute-care includes: semi-
private room and board, unlimited days, general nursing care and
the following additional facilities, services and supplies: meals and
special diets; use of operating room and related facilities; use of
intensive care or cardiac care units and related services; X-ray

services; laboratory and other diagnostic tests; drugs; medications;
biologicals; anesthesia and oxygen services; short-term physical,
speech and occupational therapy; radiation therapy; inhalation
therapy; chemotherapy; whole blood and blood products; and the
administration of whole blood and blood products.

Inpatient Stay for Lymph Node Dissection or Lumpectomy:
We will Cover inpatient services for Members undergoing a lymph
node dissection or lumpectomy for a period of time determined to
be Medically Necessary by you and your Network Physician.

Autologous Blood Banking Services: Autologous blood banking
services are Covered only when they are being provided in
connection with a scheduled, Covered inpatient procedure for the
treatment of a disease or injury. In such instances, We will Cover
storage fees for what We determine to be a reasonable storage
period that is Medically Necessary and appropriate for having the
blood available when it is needed.

Outpatient Services: The Hospital services and supplies listed
above that can be provided to you while being treated in the
outpatient facility. Please remember, unless you are receiving
preadmission testing, Hospitals are not Network Providers for
laboratory procedures and tests. Please note: lab work and X-rays
performed in a Hospital on an outpatient basis do not require
Precertification.

B. Ambulatory Surgery Center

We Cover surgical procedures performed at Ambulatory Surgical
Centers. We also Cover the Covered Services and supplies
provided by the Center the day the surgery is performed.

C. Skilled Nursing Facility

We Cover services provided in a Skilled Nursing Facility, including
care and treatment in a semi-private room, as described in
"Hospital Services" above. Custodial, convalescent or domiciliary
care is not Covered (please see the Exclusions and Limitations
section of this Certificate). In addition to Precertification, an
admission to a Skilled Nursing Facility must be supported by a
treatment plan prepared by your Network Provider and approved by
Us. We Cover non-custodial care for the amount of days shown in
your Summary of Benefits.

D. Hospice

Hospice Care is available to Members who have a prognosis of six
months or less to live. Coverage consists of palliative care rather
than curative treatment. We Cover five visits for supportive care
and guidance for the purpose of helping the Member and the
Member's immediate family cope with the emotional and social
issues related to the Member's death. Hospice Care will be
Covered only when provided as part of a Network Hospice Care
program certified by the appropriate state agency. Such certified
programs may include Hospice Care delivered by; a Hospital
(inpatient or outpatient), Home Health Care Agency, Skilled

Nursing Facility or a licensed Hospice facility. Coverage is limited
to the amount of days shown in your Summary of Benefits.
Coverage is not provided for: funeral arrangements; pastoral,
financial or legal counseling; homemaker, caretaker or respite care.

End of Life Care

Important: If a Member is diagnosed with advanced cancer and
the Member has fewer than 60 days to live, We will Cover care
provided in a licensed Article 28 facility or acute care facility (that
specializes in the care of terminally ill patients). The Members
attending physician and the facilitys medical director must agree
that the Members care will be appropriately provided at the facility.
We will reimburse such non-Network Providers as follows:

1) We will reimburse a rate that has been negotiated between Us
and the Provider.

2) If there is no negotiated rate, We will reimburse acute care at the
facilitys current Medicare acute care service rates.

3) Or if it is an alternate level of care, We will reimburse at 75% of
the appropriate Medicare rates.

4. Chemical Abuse and Chemical Dependency

All services under this section Precertification. Precertification
may be obtained by calling Medical Management at 1-800-444-
6222. Services must be provided by Network Providers who are
certified by the appropriate state agency to provide such services
and whose programs for such services have been approved by Us.

Outpatient Services

Outpatient services for the treatment of alcoholism and substance
abuse will be Covered in accordance with an individual treatment
plan prepared by your Network Provider. This benefit is limited to
the amount of visits shown in your Summary of Benefits. A limited
amount of these visits (also shown in the Summary) may be used
by the Member's family.

Coverage for: detoxification for alcoholism and substance abuse;
inpatient rehabilitation for alcoholism and substance abuse;
inpatient mental health services, and outpatient mental health
services are not Covered under this Certificate unless the Group
has purchased Supplemental Coverage which adds these benefits.
Please check the Supplemental Coverage section at the end of
this Certificate or your Summary of Benefits to verify what coverage
you have available.

5. Medical Emergencies

In order to obtain Coverage for Medical Emergencies, you should
follow the instructions below regardless of whether or not you are in
the Service Area at the time of the Medical Emergency.

We define a Medical Emergency as follows: A medical or
behavioral condition the onset of which is sudden, that manifests
itself by symptoms of sufficient severity, including severe pain, that
a prudent layperson, possessing an average knowledge of
medicine and health, could reasonably expect the absence of
immediate medical attention to result in (a) placing the health of the
afflicted Member with such a condition in serious jeopardy, or in the
case of a behavioral condition placing the health of such Member
or others in serious jeopardy; (b) serious impairment to the
Members bodily functions; (c) serious dysfunction of any bodily
organ or part of such Member; or (d) serious disfigurement of such
Member. Medical Emergencies include, but are not limited to, the
following conditions:

Severe chest pain
Severe or multiple injuries
Severe shortness
Loss of consciousness of breath
Sudden change in mental status
Severe bleedin (e.g., disorientation)
Acute pain or conditions
Poisonings requiring immediate attention
Convulsions such as suspected heart attack or appendicitis

We reserve the right to review all appropriate medical records and
make the final decision regarding the existence of a Medical
Emergency. Regarding such retrospective reviews, We will Cover
only those services and supplies that are Medically Necessary and
are performed to treat or stabilize a Medical Emergency condition.

A. Hospital Emergency Room Visits

In the event of a Medical Emergency, seek immediate care at the
nearest emergency room or call 911.

Emergency room care is not subject to Our prior approval.
However, only Medical Emergencies, as defined above, are
Covered in an emergency room. Therefore, before you seek
treatment, you may want to call to be certain that this is the most
appropriate place to receive care. You can call Our Medical
Management Coordinators. They are available 24 hours a day, 7
days a week. Your Coordinator will direct you to the emergency
room of a Hospital or other appropriate facility.

Follow-up care provided in a Hospital emergency room is not
Covered. You should contact Us to make sure you receive the
appropriate follow-up care.

B. Emergency Hospital Admissions

In the event you are admitted to the Hospital:

You or someone on your behalf must notify Us at the Medical
Emergency telephone number listed in the front of this Certificate
within 48 hours of your admission, or as soon as is reasonably
possible.

Please Note

It is important to remember that only those conditions that meet all
of the requirements contained in the definition of Medical
Emergency will be Covered as a Medical Emergency. Routine care
received in an emergency room is not Covered.

6. Urgent Care

We define Urgent Care as medical care for a condition that needs
immediate attention to minimize severity and prevent
complications, but is not a Medical Emergency.

Urgent Care is Covered in or out of the Service Area. Please
contact Oxford On Call at 1-800-444-6222. You will be provided
with instructions. Oxford On Call is available around the clock to
help you in urgent medical situations.

In addition, you may be able to use one of several Network Urgent
Care Centers in the Service Area. You do not need to contact Us
prior to, or after your visit. If Urgent Care results in an
emergency admission, please follow the instructions for
Emergency Hospital Admissions described above.

7. Ambulance Services and Prehospital
Emergency Services

Ambulance services for Medical Emergencies (as defined in this
Certificate) are Covered.

We also Cover Prehospital Emergency Medical Services. This
means We Cover the prompt evaluation and treatment of a Medical
Emergency, in addition to the non-air-borne transportation of the
patient.

Inter-facility transfers are also Covered if they are Precertified by
Us.

8. Reimbursement and Copayments

When you receive Covered Services for a Medical Emergency or
Urgent Care situation (as described above) from a non-Network
Provider, outside of the Service Area, We will limit reimbursement
to the Usual, Customary and Reasonable Charges for those
expenses incurred up to the time the Member is determined to be
able to travel to a Network Provider (please read the definition of
UCR in the Definitions section of this Certificate). Additionally,
reimbursement is subject to all applicable
Copayments/Coinsurance as similar services provided by a
Network Provider (We will reimburse less the Copayment or
Coinsurance).

You are responsible for the applicable Copayment or Coinsurance
listed in the Summary of Benefits for each office visit, emergency
room visit or emergency admission.

Section V.
Sc ope of Cover age,
Ex c l usi ons and
Li mi t at i ons

No coverage is available under this Certificate for:

1. Acupuncture therapy. We do not Cover acupuncture therapy
unless the Group has purchased Supplemental Coverage for this
benefit. Please check the Supplemental Coverage section of this
Certificate.

2. Ambulette. We do not Cover ambulette service.

3. Aphaeresis and Plasmaphaeresis. Generally, We do not
Cover aphaeresis or plasmaphaeresis on either an inpatient or
outpatient basis. Please note, all denials for the services described
above are based on Medical Necessity. If coverage is denied, you
are entitled to a Utilization Review Appeal.

4. Autopsies.

5. Birth Control. We do not Cover birth control items sold over
the counter, including but not limited to; condoms, foams or
devices, contraceptive jellies and ointments. Birth control drugs and
devises that require a prescription are not Covered under the
Certificate including those administered or implanted in a Providers
office.

However, prescription contraceptive items are Covered if the Group
purchases Outpatient Prescription Drug coverage. Please see the
Supplemental Coverage section of this Certificate to see if you
have such coverage.

Important: A Group that is a religious employer, as defined by
applicable law, may exercise its right to exclude prescription birth
control from its outpatient prescription drug coverage. In such
instances, Members may contact Us directly to inquire about
purchasing this extra coverage.

6. Blood and Blood Products. We do not Cover blood, blood
plasma, blood derivatives or synthetic blood, administered in a
Providers office or at home (unless it is part of a Home Health
Care treatment plan). Blood and blood products are Covered only
as part of an inpatient admission or procedure. The collection and
storage of blood is Covered only as described under Inpatient
Hospital Services. We do not Cover the cost of securing the
services of blood donors.

7. Care Provided in a Government Facility. We do not Cover
care or treatment provided in a non-Network Hospital that is owned
or operated by any federal, state or other governmental entity,
except as otherwise required by law.

8. Services in Connection with Elective Cosmetic Surgery. We
do not Cover cosmetic surgery, except that cosmetic surgery shall
not include reconstructive surgery when such service is incidental
to or follows surgery resulting from trauma, infection or diseases of
the involved part, and reconstructive surgery because of congenital
disease or anomaly of a Covered Dependent child which has
resulted in a functional defect.

9. Court Ordered Services. We do not Cover court ordered
services or services that have been ordered as a condition of
probation or parole. However, these services may be Covered if
We agree that the services are Medically Necessary, are otherwise
Covered, the Member has not exhausted their benefit for the
Contract Year, and the treatment is provided in accordance with
Our policies and procedures.

10. Coverage Outside of Our Network. Except for Medical
Emergencies and Urgent Care, no coverage is available outside of
Our Network of Providers.

11. Convalescent and Custodial Care. We do not Cover
services related to bed rest, rest cures, convalescent care or
custodial care. We do not Cover sanitarium care. Care is
considered custodial when it is primarily for the purpose of meeting
personal needs and could be provided by persons without
professional skills or training. For example, custodial care includes
help in walking, getting in and out of bed, bathing, dressing, eating
and orally taking medicine.

Under this Certificate, Coverage in a facility is limited to (as defined
in this Certificate): Hospitals, Skilled Nursing Facilities,
Rehabilitation Facilities (for Covered inpatient physical
rehabilitation), Hospice facilities, and Specialized Rehabilitation
Facilities (mental health and chemical dependency treatment, if
applicable).Further, Skilled Nursing Facility Care and Home Health
Care are only Covered when not providing such care would require
the Member to be placed back into the acute care Hospital. This
Certificate does not provide long-term care coverage.

12. Dental Services. We do not Cover dental services related to
the care, filling, removal or replacement of teeth. We do not Cover
the treatment of injuries or diseases of the teeth, or gums including,
but not limited to: apicoectomy, orthodontics, root canals, soft
tissue impaction, alveolectomy, and the treatment of periodontal
disease. As described in "Oral Surgery," only dental services
required to treat accidental injury of sound, natural teeth (also,
please see below) and services required to treat congenital disease
and anomaly are Covered.

Replacement of Sound Natural Teeth. Replacement of sound
natural teeth is Covered only when Medically Necessary to treat an
accidental injury, a congenital disease or a congenital anomaly.
Further, it is Covered only when repair is not possible. Please note,
all denials for the services described above are based on Medical
Necessity. If coverage is denied, you are entitled to a Utilization
Review Appeal.

13. Diet Aids. We do not Cover diet aides, supplies, membership
in diet clubs, counseling or other programs for losing weight.

14. Domiciliary Care. We do not Cover domiciliary care, long-term
care, maintenance care, adult day care or rest cures.

15. Durable Medical Equipment (DME). We Cover only those
items that meet our definition of Durable Medical Equipment.

We define Durable Medical Equipment as follows: Durable Medical
Equipment is equipment which is: 1) designed and intended for
repeated use; 2) primarily and customarily used to serve a medical
purpose; 3) generally not useful to a person in the absence of
disease or injury; and 4) is appropriate for use in the home.
Comfort or Convenience Items (please see above) are not DME. If
We deny an item because it does not meet Our definition but you or
your Network Provider believe the item does meet the definition,
you may file a Grievance as described in the Grievance Appeal
Procedure in order to determine whether or not the item is
Covered under this Certificate.

Non Standard Durable Medical Equipment and Prosthetic Devices.
We do not Cover DME or prosthetic devises that We believe are
not Medically Necessary or in excess of what is required to assist
the Member. We only Cover standard equipment. We will not Cover
customized (for a particular individual) or motorized equipment.
Please note, all denials for the equipment described above are
based on Medical Necessity. If coverage is denied, you are entitled
to a Utilization Review Appeal.

We do not Cover selectronic and neuromuscular stimulators, or
myoelectric prosthesis other than as described under Durable
Medical Equipment. Please note, all denials for the equipment
described above are based on Medical Necessity. If coverage is
denied, you are entitled to a Utilization Review Appeal.

We do not purchase Special Equipment. Special Equipment is
equipment that requires licensed professionals to interpret and take
action on any clinical data produced from the equipment. When
Medically Necessary, We will rent that equipment on a temporary
basis if licensed professionals are available on site or in the home
to assist with accurate data interpretation.

Important: We Cover only those items that meet the definition of
Durable Medical Equipment as defined in this Certificate. This
means we do not Cover the following comfort and convenience
items:

Entertainment (radio and television charges);
Communications charges (telephone or computer charges);
Barber and grooming services;
Guest meals and accommodations;
Travel expenses of the member, the members family or
guests;

Home exercise equipment that does not meet the definition of
Durable Medical Equipment; or
Household fixtures, furniture, equipment or supplies that do
not meet the definition of Durable Medical Equipment.

16. Educational Services. We do not Cover educational services.
This includes but is not limited to: 1) remedial education for:
minimal brain dysfunction, mental retardation, developmental and
learning disorders; 2) education services for behavioral problems;
and 3) evaluation of the need for educational services. Under this
Certificate, the only exception to this exclusion are the educational
services available to diabetic Members (please see, Diabetic
Supplies, Education and Self-Management).

We also do not Cover behavioral training as part of an educational
service.

17. Excess Inpatient Hospital Charges. We will not Cover
Hospital Charges that are not Covered under the section entitled
Hospital Services, Inpatient.

18. Excessive Care. We will not Cover services in excess of those
services normally required for the treatment of a condition.

19. Experimental, Investigational or Ineffective; Surgical or
Medical Treatments. We Cover do not experimental,
investigational or ineffective; surgical or medical treatments,
procedures, drugs, or research studies including, but not limited to:
transplants, stem cell retrieval, cancer chemotherapy protocols,
AIDS clinical trials or I.V. therapies that are not recognized as
acceptable medical practice and any such services where federal
or other governmental agency approval is required but has not
been granted. We will make the determination as to whether the
requested service is excluded in accordance with this provision. In
certain instances, such procedures may be Covered if they are
approved in advance by one of Our Medical Directors in
accordance with terms of the Certificate and Our payment policies
if the We determine that Member has a life threatening or disabling
condition and/or disease and:

a. The Members attending Network Physician certifies that the
Member has a life threatening and/or disabling condition or disease
for which; 1) standard health services or procedures have been
ineffective or would be medically inappropriate; or 2) for which
there does not exist a more beneficial standard of health service or
procedure Covered by the health care plan, or 3) for which there
exists a clinical trial, and

b. The Members attending Network Physician (who must be board
certified to treat the life threatening or disabling condition) must
recommend either 1) the procedure based on at least two clinical
peer reviewed documents which established that the treatment is
likely to be more beneficial than any standard treatment for the
Members life threatening or disabling disease. If no standard
treatment can be used to make such a comparison, the attending

Network Physician must show, through scientific published data,
that medical investigations conclude that the experimental
/investigational treatment may be effective when treating the
Members particular disease or condition; or 2) a clinical trail for
which the Member is eligible.

IMPORTANT: If an External Appeal Agent approves coverage of
an experimental or investigational treatment that is part of a clinical
trial, We will only Cover the cost of services required to provide
treatment to you according to the design of the trial. We shall not
be responsible for the costs of investigational drugs or devices, the
costs of non-health care services, the costs of managing research,
or costs which would not be Covered under this Certificate for non-
experimental or non-investigational treatments provided in such
clinical trail.

We will Cover autologous bone marrow transplants combined with
high dose chemotherapy when medically appropriate, for the
treatment of: advanced neuroblastoma, second remission acute
leukemia, relapsed Hodgkin's disease, relapsed non-Hodgkin's
lymphoma, or any other diagnosis that Our Medical Advisory Board
determines to be appropriate. We will make the determination of
when such treatment is medically appropriate. Such treatment must
be approved in advance by one of Our Medical Directors and
provided in accordance with the provisions of this Certificate.

In some instances, your Provider may believe such an
item/procedure is experimental or investigational as described
above, and is Medically Necessary. We may disagree. However,
coverage is available once the experimental/investigational status
has been determined and Medical Necessity has been established.

20. Food. We do not Cover food, including special foods and diets,
vitamins, or nutritional or other supplements, (except when
provided in an inpatient setting). Enteral and parenteral nutrition
services provided on an outpatient basis are also excluded. If the
Group has purchased an Outpatient Prescription Drug option,
some of these supplies may be available. Please check the
have this coverage. When coverage of special foods, diets and
enteral feedings is available, it is subject to periodic review for
Medical Necessity.

21. Fraud. We do not Cover any procedures, services or supplies
if they have been fraudulently obtained.

22. Growth Hormones. We do not Cover growth hormones for a
naturally small child who can perform ADL and who does not have
a either a deficiency of growth hormone or a biological inability to
produce growth hormone in its normal biological composition
(growth hormone bio-inactivity). Coverage is available for children
who do have either problem, as described in this Certificate. Please
note, all denials related to the services described above are based
on Medical Necessity. If coverage is denied, you are entitled to a
Utilization Review Appeal.

23. Hearing Aids.

24. Improper Use of an Emergency Room. We do not Cover the
improper use of an emergency room or emergency admissions.
Routine care and treatment for conditions that could not have
presented themselves to the average prudent lay person as a
Medical Emergency are not Covered when treated in an
emergency room. We do not Cover improper transportation to
emergency rooms. If coverage is denied, you are entitled to a

25. Infertility Treatment. We do not Cover infertility treatment
except as required by law and, regarding Advanced Services, as
specifically Covered under this Certificate, and all costs for and
relating to surrogate motherhood (maternity services are Covered
for Members acting as surrogate mothers). We also do not Cover
services to reverse voluntary sterilizations.

26. Inpatient Treatment for Alcoholism or Drug Abuse. We do
not Cover inpatient treatment for alcoholism or drug abuse
including rehabilitation services in a specialized inpatient or
residential facility.

However, the Group may elect to add additional coverage for
inpatient alcohol and substance abuse treatment. Please check the
have this coverage.

27. Hospital Stays for Diagnostic Studies. We will not Cover
any Hospital stay or a portion of a Hospital stay, that is primarily for
diagnostic purposes. This exclusion applies to a Hospital stay or a
portion of a Hospital stay during which the services you receive are
primarily for diagnostic X-rays, laboratory tests, or other types of
diagnostic studies.

28. Long-Term Rehabilitation Services for Physical Therapy.
We do not Cover long-term rehabilitation services for physical
therapy Coverage is limited to short-term physical therapy as
defined in this Certificate.

However, the Group may purchase Long Term Physical Therapy
coverage. Please check the Supplemental Coverage section of
this Certificate to see if you have this coverage.

29. Membership in Health Clubs. Stays at Spas, Resorts, and
other Residential Facilities We do not Cover membership in health
clubs, gyms or similar establishments. We do not Cover spa
treatments, rest cures or vacations. We do not Cover stays at spas,
resorts, residential facilities or any other similar facility. Coverage
under this Certificate for room and board is limited to (as defined in
this Certificate): Hospitals, Skilled Nursing Facilities, Rehabilitation
Facilities (for Covered inpatient physical rehabilitation), Hospice
facilities, and Specialized Rehabilitation Facilities (mental health
and chemical dependency treatment, if applicable).

30. Mental Health Services. We do not Cover mental health
services (inpatient and outpatient).However, the Group may
purchase additional coverage for the treatment of mental health
and behavioral disorders. Please check the Supplemental
Coverage section of this Certificate to see if you have such
coverage.

31. Military Service Related Conditions. We do not Cover
conditions that are connected with a Member's service in the
military and for which the Member is legally entitled to receive
services at a government facility provided the facilities are
reasonably available to the Member (a maximum drive time of 30
minutes or 20 miles).

32. Non-Acute Hospital Care. We will not Cover any Hospital
stay, or any portion of a Hospital stay during which you received
non-acute care. This exclusion applies to a Hospital stay or any
portion of a Hospital stay in connection with physical check-ups,
convalescent or custodial care, rest cures, or sanitarium type care.
Care is considered custodial when it is primarily for the purpose of
meeting personal needs and could be provided by persons without
professional skills or training. For example, custodial care includes
help in walking, getting in and out of bed, bathing, dressing, eating
and orally taking medicine.

33. Non-Eligible Institutions. We do not Cover non-eligible
institutions. We do not Cover any services or supplies furnished
by a non-eligible institution, which is defined as other than a
Hospital or Skilled Nursing Facility, and which is primarily a place of
rest, a place for the aged, or any similar institution, regardless of
how denominated.

34. Non-Medical Services.

35. No Show or Late Charges.

36. Nutritionists and Related Services. We will not Cover the
services of nutritionists or special dietary products except as
specifically Covered under this Certificate. We will not Cover weight
counseling.

37. Orthotics. We do not Cover orthoics.

38. Over-the-Counter Medications and Supplies. Except as
otherwise Covered under this Certificate under Medical Supplies
and supplies for diabetics, We do not Cover over-the-counter
medication, drugs, medical supplies, or devices.

39. Preexisting Conditions. Starting from the Enrollment Date,
We will not provide Covered Services for a Preexisting Condition
for the first 12 months of coverage under this Certificate.
However, We will credit the time a Member was covered under
Prior Continuous Creditable Coverage. In the case of previous
HMO coverage, any affiliation period prior to the previous coverage
becoming effective will also be credited.

40. Prescription Drugs. We do not Cover prescription drugs
except for drugs: 1) furnished to a Member (as an inpatient) in
connection with a Covered Hospital stay, 2) administered during a
Covered outpatient procedure, 3) furnished to a Member as part of
their Home Health Care benefit, 4) furnished to a Member under
their Skilled Nursing Facility benefit, or 5) furnished to a Member as
part of their Hospice benefit.

Additionally, except for chemotherapy, We do not Cover outpatient
prescription drugs and devises that are administered or implanted
in a Providers office.

Coverage is available for FDA approved prescription drugs if the
Group has purchased an Outpatient Prescription Drug option.
Please check the Supplemental Coverage section of this
Certificate to see if you have this coverage.

41. Private or Special Duty Nursing.

42. Recreational, Educational and Sleep Therapy. We do not
Cover recreational, educational or sleep therapy.

43. Refractive Eye Surgery. Generally, We do not Cover
refractive eye surgery including but not limited to: LASIK, Laser
Thermal Keratoplasty, Orthokeratology, Standard Keratomeluesis,
Astigmatic Keratotomy, Photoreactive Keratotomy, Radial
Keratotomy, Epikeratoplasty, Keratophakia Keratomileusis. Please
note, all denials regarding these surgeries are based on Medical
Necessity. If coverage is denied, you are entitled to a Utilization
Review Appeal.

44. Routine Foot Care. We do not Cover foot care, in connection
with corns, calluses, flat feet, fallen arches, weak feet, chronic foot
strain or symptomatic complaints of the feet.

45. Services and Benefits for which the Member is Entitled to
Other Coverage as follows:

Workers Compensation. We do not Cover services for the
treatment of occupational conditions, ailments, or injuries
arising out of and in the course of employment. Such
conditions, ailments or injuries are not Covered if they are
subject to coverage, in whole or in part, under any workers'
compensation, occupational disease or similar federal or state
law.

Medicare. We do not Cover services covered by the federal
Medicare program when Medicare is the primary payor, We
Cover the services provided by this Certificate only to the
extent they are not covered under Medicare. Please see the
General Administrative Policies and Procedures, and
Medicare and Other Government Programs sections of this
Certificate.

An Adopted Newly Born Infant's Initial Hospital Stay. We
do not Cover an adopted newly born infant's initial hospital
stay if the natural parent has coverage available for the
infant's care.

No-Fault Automobile Insurance. We do not Cover any
Covered Services that are payable as personal injury benefits
under mandatory no-fault automobile insurance. Where
permitted by state law, any Covered Services which are
eligible for payment under the provisions of an automobile
insurance contract or pursuant to any federal or state law
which mandates indemnification for such services to persons
suffering bodily injury from motor vehicle accidents are not
Covered.

46. Services for which the Member has No Legal Obligation.
We do not Cover supplies or treatment for which the Member has
no legal obligation to reimburse the Provider. Any supply or
treatment provided by the Subscribers spouse or immediate family
or the immediate family of the Subscribers spouse is not Covered.
Immediate family shall mean a: child, spouse, mother, father,
sister, or brother of the Subscriber or the Subscribers Spouse.

47. Services not Listed. We will not Cover services that are not
listed in this Certificate as being Covered.

48. Services Under Appeal. If there is a dispute between a you
or a Provider and Us regarding whether or not a services is
Covered or Medical Necessary, you or your Provider may appeal
Our decision (please refer to Section VI. of this Certificate).
However, except for Hospice services, any disputed service or
supply will not be Covered during the Appeal process.

Additionally, if you and a Network Provider agree that you will be
responsible for the costs of Covered Services that We have
determined are not Covered or Medically Necessary, We will not
reimburse you.

49. Sexual Dysfunction. We do not Cover medical or surgical
treatment of sexual dysfunction unless the dysfunction is
biologically-based and/or the result of physical injury or impairment.
Counseling for sexual dysfunction is Covered only if the Group has
purchased Supplemental Coverage for mental health services.
Please check the Supplemental Services section of this
Certificate. Please note, all denials are based on Medical
Necessity. If coverage is denied for the above described services,
you are entitled to a Utilization Review Appeal.

50. Smoking Cessation. We will not Cover smoking cessation
programs, devices or services.

51. Special Medical Reports. We do not Cover special medical
reports not directly related to treatment. We do not Cover
appearances in court or at a hearing.

52. Speech Therapy. We do not Cover speech therapy to correct
a condition that is not the result of a disease, injury or a congenital
defect for which surgery has been performed. In no event will We
Cover speech therapy that continues beyond 365 days after such
event.

53. Stand-by Services. We will not Cover stand-by services.
Stand-by services are services that a Provider performs relating to
being available to provide services on a contingent basis, Mere
standing-by is not Covered. Stand-by services may be deemed to
be rendered by any Provider. Listed below are examples of two
types of stand-by services:

Example One. The administration of anesthesia is not a stand-by
services. It is a Covered Service. The services listed below when
rendered by an anestheiologist are not Covered. They are deemed
stand-by services:

Preparing a contingency anesthesia plan.
Merely being in the operating area.
Merely being in the Hospital.
Being available for diagnosis and treatment on a contingency basis
if needed.

Example Two. Stand-by services may be performed by a surgeon.
Surgery or assisting at surgery are not stand-by services. They are
Covered Services. The services listed below when performed by a
surgeon are not Covered. They are deemed stand-by services:

Preparing a contingency surgery plan.
Merely reviewing a patients chart.
Merely being in the operating area.
Merely being in the Hospital
Being available for diagnosis, treatment or surgery on a contingent
basis if needed.

54. Third Party Physical Examinations. We do not Cover
physical examinations, diagnostic services or immunizations in
connection with: obtaining or continuing employment; obtaining or
maintaining any license issued by a municipality, state or federal
government; obtaining insurance coverage; foreign travel; school
admissions or attendance including examinations required for
participation in athletic activities.

Court ordered psychological or behavioral evaluations or
counseling related to marital disputes, divorce proceedings, or child
custody proceedings are not Covered unless the Group has
purchased Supplemental Coverage for mental health services
(please check the Supplemental Services section of this
Certificate) and such benefit has not been exhausted.

55. TMJ. Dental procedures and appliances for the treatment for
TMJ (temporomandibular joint syndrome or dysfunction;
craniomandibular pain syndrome) are never Covered. However,
surgical and nonsurgical medical procedures and orthognathic
surgery are Covered if Precertified and approved by Our Medical
Director. Please note, all denials for the treatment of TMJ are
based on Medical Necessity. If coverage is denied, you are entitled
to a Utilization Review Appeal.

56. Transplant Services. We do not Cover transplant services
required by a Member when the Member serves as an organ
donor, unless the recipient is a Member. The medical expenses of
a non-Member acting as a donor for a Member are not Covered if
the non-Member's expenses will be covered under another health
plan or program. Donor fees in connection with organ transplant
surgery are excluded. Routine harvesting and storage of stem cells
from newborn cord blood is not Covered. We do not Cover travel
expenses, lodging, meals or other accommodations for donors or
guests. Transplants performed in facilities other than those
designated by Us for the transplant procedure are not Covered.

57. Unnecessary Care. In general, We will not Cover any health
care service that We in Our sole judgment, determine is not
Medically Necessary. If an External Appeal Agent certified by the
State overturns Our denial, however, We shall Cover the
procedure, treatment, service, pharmaceutical product, or Durable
Medical Equipment for which coverage has been denied, to the
extent that such procedure, treatment, service, pharmaceutical
product, or Durable Medical Equipment is otherwise Covered under
the terms of this Certificate.

58. Usual, Reasonable and Customary (UCR). We do not Cover
any charges for Covered Services by a Non-Network Provider that
are in excess of UCR charges (as determined by Us). Such
charges are the Member's responsibility. Please see the definition
of UCR in the Definitions section of this Certificate.

59. Vision Correction Services and Supplies. We do not Cover
vision correction services or supplies: eyeglasses (lenses and
frames), all manner of contact lenses or corrective lenses, and
refractions (examinations for the prescription) or fitting thereof
unless the Group has purchased Supplemental Coverage for this
benefit. Please see the Supplemental Coverage section of this
Certificate.

When performed solely for vision correction, We do not Cover eye
exercises, visual training, vision therapy or orthoptics.

60. War. We will not Cover services for care of illness or injury due
to war, declared or undeclared.

61. Weight Control. We do not Cover surgical procedures for the
purpose of weight control unless Medically Necessary for the
treatment of morbid obesity. Please note, all denials for the
services described above are based on Medical Necessity. If
coverage is denied, you are entitled to a Utilization Review Appeal.

Section VI.
How Wi l l t he Pl an Handl e
Any Quest i ons or
Pr obl ems?

Under New York State law, your completed request for an Appeal
must be filed within 45 days of either the date upon which you
receive written notification from Us that We have upheld a denial of
coverage during the internal Appeal process or the date upon
which you receive a written wavier of any internal Appeal. We have
no authority to grant an extension to this deadline.

Our Grievance Procedure provides for a meaningful, dignified and
confidential procedure to hear and resolve Grievances between
Members, Us and, when necessary, Network Providers. This
Grievance Procedure also assures that Grievances are handled in
a timely manner.

To make this process more accessible to non-English speaking
Members, We will arrange to have an interpreter available who
speaks your language. Because the interpreter will be an employee
of an independent translating service, Our ability to provide this
service depends on the availability of the interpreter. We may need
to arrange to call you at a time when an appropriate interpreter is
available. Additionally, you always have the right to designate a
representative to represent you during the Grievance Procedure.
You must provide us with a written consent in order for the
designee to act on your behalf. A copy of the Grievance Procedure
is available in many languages. Depending on availability, a copy in
your language can be forwarded to you upon your request.

IMPORTANT: All Complaints, and First Level Appeals must be
initiated 180 days from the receipt of the Explanation of Benefits,
Denial Notice, or of the date when the Member became aware of
the issue that initiated the Complaint or Appeal.

Grievance Overview

Grievances and Complaints are classified into two categories. The
category of the specific issue will determine which process You will
need to follow in resolving your issue. The two categories are:

1. Benefit/Administrative Issues The types of items that fall
under this category include, but are not limited to, problems
with any of Our administrative policies, issues concerning
access to providers, denials based on benefit exclusions or
limitations, claims payment disputes, and administrative
inquires. If this relates to your issue, refer to section I.
Grievance Procedure for Benefit/Administrative Issues
for further information.

2. Utilization Review Issues This category includes those
items, which concern Medically Necessary determinations.
The Utilization Review category also includes determinations
involving treatment or services that are considered
Experimental or Investigational. If this relates to your issue,
refer to section II. Grievance Procedure for Utilization
Review Issues for further information.

I. Grievance Procedure for
Benefit/Administrative Issues

A. Timeframes for Initial Determinations for
Benefit/Administrative Issues

1. A request for Service (Pre-Service); We will inform you and
your Provider of Our decision, by telephone and in writing, no
later than 15 days from receipt of the request.

2. Coverage for a service already rendered. (Post-Service);
We will inform you of Our decision within 30 days of Our

3. A request for Urgent Care: We will inform You or your
provider, Subject to Medical Appropriateness, not later than 72
hours after the receipt of the claim. This includes any claim
for medical service that if subjected to the standard time
frames, could seriously jeopardize the life or health of the
covered person.

Please note: We will inform you and your Provider of Our decision,
by phone and in writing, within the time frames stated above. Once
the review is complete, he or she will provide you with Our written

or electronic notification. Our response will include Our decision on
the Initial Benefit Determination as well as the detailed reasons for
the decision, including the clinical rationale if applicable, along with
references to any applicable specific plan provisions on which the
benefit determination was based. It will also include information on
how to file a First Level Grievance, and information on how the
claimant is entitled to receive, upon request and free of charge,
reasonable access to, and copies of, all documents, records, and
other information relevant to the claimants claim for benefits. The
timeframes stated in this section might change if We need
additional information from you in order to process your claim, or
request for service:

We will notify You or your provider within the timeframes stated
above that there is a lack of information to process either your
request for service or your claim for a service already rendered.
You will have up to 45 days to provide the additional information.
The 45 day period is calculated from the date you receive Our
request for information. A determination will be rendered within 15
days of receipt of the information or 15 days from the expiration of
the period of time allowed to provide the information.

For Urgent Care Services, information will be requested by Us
within 24 hours of receipt of the request; you will have 48 hours to
provide Us with the information necessary to complete your request
for service. We will render a decision within 48 hours of receipt of
the information, or the expiration of the original request for
additional information, whichever is sooner.

In all cases, if no information is received within the required
timeframes, the claim or request for service will be denied.

Please Note: The Grievance Procedure described below should be
used when you have a problem with any of Our policies,
procedures or determinations (Our administrative procedures,
access to providers, failure to use a Network Provider, Covered
benefits under the Certificate, etc.) except for issues concerning
Medical Necessity. All issues concerning Our determination of
Medical Necessity must be resolved through the Grievance
Procedure for Utilization Review Issues process described in
Section II.

There are two basic elements to the Grievance Procedure for
Benefit Administrative Issues for Members, Complaints and
Appeals as described below.

B. Complaints

You may advise Us of a problem by calling a Customer Care
Representative 1-800-444-6222. The Customer Care
Representative will attempt to resolve your Complaint at the time of
the call. If you remain dissatisfied, or for complaints that are not
resolved at the time of the call, you may file a Grievance by
following the procedure outlined below.

C. Grievance Appeal Procedure

First Level Grievance

You have the right to request a review of Our initial determination.
You or your designee must file a Grievance within 180 days of
receipt of the Explanation of Benefits, Denial Notice, or of the date
when You became aware of the issue that initiated the Grievance.
You may file a Grievance, either by telephone or in writing with Our
Correspondence Department. The staff of the Correspondence
Department will acknowledge receipt of the Grievance, in writing,
within 5 business days of receipt. The acknowledgment will
include the contact information for the Department, which has been
designated to investigate the grievance and indicate if any
additional information is needed.

An individual in the Department will conduct a review of the
Grievance. Once the review is complete, he or she will provide you
with Our written or electronic notification. Our response will include
Our decision on the Grievance as well as the detailed reasons for
the decision, including clinical rationale if applicable, along with
how to file a Second Level Appeal, and information on how the
other information relevant to the claimants claim for benefits.

We will advise you, your designee, or Provider (if applicable) of Our
decision:

Not later than 30 days from the Correspondence
Departments receipt of a Grievance for services that have
already been received.

Not later than 15 days from the Correspondence
Departments receipt of a Grievance for the request for
services or treatment that has not yet been received.

Not later than 45 days of receipt of all necessary information
for administrative matters concerning our participating
providers.

If Oxford upholds its prior determination, the Member will receive
Second Level Appeal rights in the determination letter

Expedited Grievance Procedure

Occasionally, medical circumstances require that certain
procedures be performed without significant delay. When the time
frames of the normal Grievance process would seriously jeopardize
the Members life or health, their ability to regain maximum
function, or in the opinion of a doctor with knowledge of the health
condition, cause the Member severe pain that cant be managed
without the requested services, the Grievance Review Board will,
upon notification, render a decision that will include written
notification to the Member, within 48 hours from receipt of all
necessary information or 72 hours from receipt of the Grievance,
whichever is shorter. Grievances for determinations of services
that have already been provided cannot be appealed on an
expedited basis.

Second Level Appeal Procedure

If You remain dissatisfied with the results of the Grievance
determination, You or your designee may Appeal to the Grievance
Review Board (the Board). You have 60 business days from the
date on which you received notice of the Correspondence
Department's determination. We will acknowledge the receipt of the
Members appeal within 15 business days of the receipt of the
Appeal requests. The acknowledgement will include the name,
address and telephone number of the individual who has been
designated to investigate your Appeal and indicate if any additional
information is needed.

The Board will make its decision on the Second Level Appeal not
later than:

30 days from the Boardsreceipt of an Appeal for services that
have already been received.

15 days from the Boards receipt of an Appeal for the request
for services or treatment that has not yet been received.

2 business days after receipt of necessary information when
a delay would significantly increase the risk to an enrollees
health.

The Board will:

1. Rule that the Appeal is valid and recommend corrective action
to resolve the matter; or

2. Rule that the Appeal is without merit and does not require
further action.

You will receive written notice of the Board's decision. Once the
review is complete, We will provide you with Our written or
electronic notification. Our response will include Our decision on
the Appeal as well as the detailed reasons for the decision,
including the clinical rationale if applicable, along with references to
any applicable specific plan provisions on which the benefit
determination was based. And information on how the claimant is
entitled to receive, upon request and free of charge, reasonable
access to, and copies of, all documents, records, and other
information relevant to the claimants claim for benefits.

The Board is a committee of Our employees appointed for the
express purpose of reviewing and resolving Member Appeals.
When an Appeal is clinical in nature, the Board will include a
licensed, certified or registered individual who did not review the
issue at the First Level Grievance. If the Appeal pertains to an
administrative issue, individuals of a higher level than those who
reviewed the First Level Grievance will resolve the Second Level
Appeal.

The ruling of the Grievance Review Board will be Our final position.

Members may write to either (or both) the New York State
Insurance Department or the Department of Health, Office of
Managed Care, Bureau of Managed Care Certification and
Surveillance at any time during the Grievance process

Consumer Services Bureau
State of New York Insurance Department
25 Beaver Street
New York, NY 1004-2319
(212) 602-0203

Office of Managed Care
Bureau of Managed Care
Certification and Surveillance
New York Department of Health
Corning Tower - Room 1911
EmpireState Plaza
Albany, NY 12237
(518) 474-2121

Please note: You may also call the Department of Health
1-800-206-8125 at anytime during the Grievance Procedure
process. You do not have to wait until the process is exhausted.

All information pertaining to each Complaint and Appeal will be fully
documented, and we will retain such records for at least three
years.

II. Grievance Procedure for Utilization Review
Issues
Please Note: This procedure must be used whenever your issue
concerns Our determination that a Covered Service is not Medically
Necessary. Complaints, and Appeals concerning all other Non-
Medical Necessity determinations will be addressed through the
Grievance Procedure for Benefit Administration Issues as
described above.

A. Utilization Review

Covered Services are subject to Utilization Review. This means
that our Medical Management Department reviews pertinent
medical information in order to determine whether or not the
proposed service (request for Precertification), the service currently
being provided (Concurrent Review), or the service that was
provided (Retrospective Review) is a Covered Service under the
Certificate and Medically Necessary. If any of the following occur
because We have made the determination that such service is
not Medically Necessary (Adverse Determination), you may
appeal that determination:

A request for Precertification. We will inform you and your
Provider of Our decision, by telephone and in writing, no later
than 3 business days from receipt of the necessary
information.

Coverage for a current service for a member in an ongoing
course of treatment. We will inform you and/or your Provider
of Our decision, by phone and in writing, within 1 business
day of our receipt of all necessary information; Coverage for a
urgent current service for a member in an ongoing course
of treatment shall be decided as soon as possible, taking into
account the medical exigencies, We will notify the claimant of
the benefit determination, whether adverse or not, within 24
hours after receipt of the claim by the plan, provided that any
such claim is made to the plan at least 24 hours prior to the
expiration of the prescribed period of time or number of
treatments.

Coverage for a service already received is denied
(Retrospective Review). We will inform you of Our decision
within 30 days of Our receipt of the claim.

Please note: We will inform you and your Provider of Our decision,
by phone and in writing, within the time frames stated above. Once
the review is complete, We will provide you with Our written or
the Initial Benefit Determination as well as the detailed reasons for
the decision, including the clinical rationale if applicable, along with
how to file a First Level Appeal, and information on how the
other information relevant to the claimants claim for benefits.

If We fail to make a determination within these timeframes, the
request will be deemed an Adverse Determination subject to the
appeals provisions below.

The timeframes stated in this section might change if We need
additional information from you in order to process your claim, or
request for Precertification:

1. A request for Service (Pre-Service): We will notify You or
your provider within 15 days that there is a lack of information
to process your request for service. You will have up to 45
days to provide the additional information. The 45-day period
is calculated from the date you receive Our request for
information. A determination will be rendered within 3
business days of receipt of the additional information, if
received within 45 days, or 15 days from the expiration of the
period of time allowed to provide the information.

2. Coverage for a service already rendered. (Post-Service);
We will notify You or your provider within 30 days that there is
a lack of information to process your claim for a service
already rendered. You will have up to 45 days to provide the
additional information. The 45-day period is calculated from
the date you receive Our request for information. A
determination will be rendered within 15 days of receipt of the
additional information, if received within 45 days, or 15 days
from the expiration of the period of time allowed to provide the
information.

3. A request for Urgent Care: For Urgent Care Services,
information will be requested by Us within 24 hours of receipt
of the request; you will have 48 hours to provide Us with the
information necessary to complete your request for service.
We will render a decision within 48 hours of receipt of the
information, or the expiration of the original request for
additional information, whichever is sooner.

In all cases, if no information is received within the required
timeframes, the claim or request for service will be denied.

B. Appeal Procedure for Utilization Review Issues; Appealing
Adverse Determinations

The Member or the Members designee may appeal Adverse
Determinations relating to Precertification and Concurrent Review.

You must provide us with a written consent in order for the
designee to act on your behalf. In the event that We render an
adverse determination without attempting to discuss the matter with
the Members health care provider who specifically recommended
the health care service, procedure or treatment under review, The
Members Provider may request a reconsideration of the adverse
determination. If We make such an Adverse determination without
attempting to discuss the matter with the Members Provider, We
will respond within one business day of Our receipt of the request
for reconsideration.

Retrospective Adverse Determinations may be appealed by either
the Member, the Members designee or the Members Provider.

All Appeals may be initiated either in writing or by telephone.
Clinical personnel who did not participate in the initial review will
review all Appeals.

First Level Appeal

After you are informed of the Adverse Determination, you, your
designee or your Provider (if applicable) have up to 180 days to
initiate the Appeal process. The person initiating the Appeal must
write or telephone Us within this 180-day period. To initiate an
Appeal, please call Customer Care at 1-800-444-6222 or write to
Clinical Appeals Department at P.O. Box 29139, Hot Springs, AR
71903-29139. We will acknowledge the receipt of your Appeal
within 5 business days of the receipt of the Appeal requests. The
acknowledgment will include the name, address and telephone
number of the individual who has been designated to investigate
your Appeal.

We will advise you, your designee, or Provider ( if applicable) of
Our decision:

1. Not later than 30 days from the Clinical Appeals Departments
receipt of an Appeal for services that have already been
received.

2. Not later than 15 days from the Clinical Appeals Departments
receipt of an Appeal for the request for Precertification or
concurrent care.

3. Within 2 business days of receipt of all necessary
information, (but in no event no later than 72 hours) of
receipt of a request for urgent Precertification or Concurrent
Services.

If the Adverse Determination is upheld, you will receive written or
determination was based. It will also include information on how to
file a Second Level Appeal and/or an External Appeal, and
information on how the claimant is entitled to receive, upon request
and free of charge, reasonable access to, and copies of, all
documents, records, and other information relevant to the claimants
claim for benefits.

If you disagree with the first level appeal determination you may
appeal to the Grievance Review Board described below under
Second Level Appeal and/or go directly to the New York State
external appeal process described in Section III. The 45 day
timeframe for requesting an external appeal begins upon the
receipt of the final adverse determination of the first level appeal,
regardless of whether or not a second level appeal is requested, by
choosing to request a second level internal appeal, the time may
expire for You to request an external appeal. However, if you
choose to pursue simultaneously an External Appeal and a Second
Level Appeal, Oxford reserves the right to waive the Second Level
Appeal process and, in lieu of a Second Level Appeal, Oxford will
be bound by the decision of the external appeal agent. In such
case, you will not be required to complete a Second Level Appeal
in order to exercise any rights you may have under ERISA.

If We fail to make an Adverse Determination Appeal decision
within;

2 business days of receipt of necessary information for
Expedited Appeals; or

60 days of the receipt of necessary information for Utilization
Review Appeals;

The original Adverse Determination will be reversed.

III. Expedited Utilization Review Appeal

If you are in an ongoing course of treatment and are seeking
continued or extended services, or your Provider believes that an
immediate Appeal is necessary because the time frames of the
Utilization Review Appeal process would significantly increase the
risk to your health, then you, your designee or your Provider may
request an Expedited Utilization Review Appeal. Retrospective
Final Adverse Determinations cannot be appealed on an
expedited basis.

The Appeal may be made in writing or by telephone. Within one
day of Our receipt of the Appeal, We will provide reasonable
access to Our clinical peer reviewer. We will provide access to Our
facsimile machines or other services as needed. Oxford will render
a decision to either uphold or reverse the Adverse Determination.
The decision will include written notification to the Member; within 2
business days from receipt of all necessary information or 72
hours from receipt of the appeal, whichever is shorter. If you
continue to be dissatisfied with the decision of the Expedited
Appeal, you may Appeal that decision through the Appeal
Procedure for Utilization Review Issues described above, or you
may Appeal that decision through the External Appeal process
described below. If you disagree with the Expedited Appeal
determination you may file a First Level Appeal and/or go directly to
the New York State external appeal process described in Section
III. The 45-day timeframe for requesting an external appeal begins
upon the receipt of the final adverse determination of the Expedited
Appeal, regardless of whether or not a First level appeal is
requested, by choosing to request a first level internal appeal, the
time may expire for You to request an external appeal.

Second Level Appeal

If you are still dissatisfied with the results after the First Level
Appeal has been completed, you or your designee may file your
written Appeal with the Grievance Review Board (the Board).
This Appeal must be filed within 60 business days of the date on
which you received notice of the First Level Appeal determination
letter. We will respond to the receipt of the Members appeal within
15 business days of the receipt of the Appeal requests. The
response will include the name, address and telephone number of
the individual who has been designated to investigate your Appeal.

The Board will make its decisions not later than:

30 days from the Boards receipt of an Appeal for services
that have already been received.

15 days from the Boards receipt of an Appeal for the request
for Precertification or Concurrent Care.

The Board will:

1. Rule that the Appeal is valid and recommend corrective action
to resolve the matter; or

2. Rule that the Appeal is without merit and does not require
further action.
You will receive written notice of the Board's decision. Once the
review is complete, We will provide you with Our written or
determination was based. And information on how the claimant is
entitled to receive, upon request and free of charge, reasonable
access to, and copies of, all documents, records, and other
information relevant to the claimants claim for benefits.

The ruling of the Grievance Review Board will be Our final position.

Members may write to either (or both) the New York State
Insurance Department or the Department of Health, Office of
Managed Care, Bureau of Managed Care Certification and
Surveillance at any time during the appeal process.

Consumer Services Bureau
Office of Managed Care
State of New York Insurance Department
Bureau of Managed Care
25 Beaver Street
Certification and Surveillance
New York, NY 10004-2319

New York Department of Health
1-800-342-3736
Health Corning Tower - Room 1911
Empire State Plaza
Albany, NY 12237
(518)-474-4156

Please note: You may also call the Department of Health
1-800-206-8125 at anytime during the Grievance Procedure
process. You do not have to wait until the process is exhausted.

All information pertaining to each initial adverse determination and
Appeal will be fully documented, and we will retain such records for
at least three years.

IV. EXTERNAL APPEAL

A. YOUR RIGHT TO AN EXTERNAL APPEAL

Under certain circumstances, you have a right to an External
Appeal of a denial of coverage. Specifically, if We deny coverage
on the basis that the service is not Medically Necessary or is an
experimental or investigational treatment, you or your
representative may appeal that decision to an External Appeal
Agent, an independent entity certified by the State to conduct such
Appeals.

B. YOUR RIGHT TO APPEAL A DETERMINATION THAT A
SERVICE IS NOT MEDICALLY NECESSARY

If We deny coverage on the basis that the service is not Medically
Necessary, you may appeal to an External Appeal Agent if you
satisfy the following two criteria:

The service, procedure or treatment must otherwise be a
Covered Service under this Certificate; and

You must have received a Final Adverse Determination
through Our internal review process, and We must have
upheld the denial, or you and We must agree in writing to
waive any internal Appeal.

C. YOUR RIGHT TO APPEAL A DETERMINATION THAT A
SERVICE IS EXPERIMENTAL OR INVESTIGATIONAL

If you have been denied coverage on the basis that the service is
an experimental or investigational treatment, you must satisfy the
following two criteria:

The service must otherwise be a Covered Service under this
Certificate; and

You must have received a Final Adverse Determination
through Our internal appeal process and We must have
upheld the denial, or you and We must agree in writing to
waive any internal appeal.

In addition, your attending physician must certify that you have a
life-threatening or disabling condition or disease. A life-threatening
condition or disease is one, which, according to the current
diagnosis of your attending physician, has a high probability of
death. A disabling condition or disease is any medically
determinable physical or mental impairment that can be expected
to result in death, or that has lasted or can be expected to last for a
continuous period of not less than 12 months, which renders you
unable to engage in any substantial gainful activities. In the case of
a child under the age of 18, a disabling condition or disease is any
medically determinable physical or mental impairment of
comparable severity.

Your attending physician must also certify that your life-threatening
or disabling condition or disease is one for which standard health
services are ineffective or medically inappropriate or one for which
there does not exist a more beneficial standard service or
procedure Covered by Us or one for which there exists a clinical
trial (as defined by law).

In addition, your attending physician must have recommended one
of the following:

A service, procedure or treatment that two documents from
available medical and scientific evidence indicate is likely to be
more beneficial to you than any standard Covered Service
(only certain documents will be considered in support of this
recommendation your attending physician should contact
the State in order to obtain current information as to what
documents will be considered acceptable); or

A clinical trial for which you are eligible (only certain clinical
trials can be considered).

For the purposes of this section, your attending physician must be
a licensed, board-certified or board eligible physician qualified to
practice in the area appropriate to treat your life-threatening or
disabling condition or disease.

D. THE EXTERNAL APPEAL PROCESS

If, through Our internal review process, you have received a Final
Adverse Determination upholding a denial of coverage on the basis
that the service is not Medically Necessary or is an experimental or
investigational treatment, you have 45 days from receipt of such
notice to file a written request for an external appeal.

If you and We have agreed in writing to waive any internal appeal,
you have 45 days from receipt of such waiver to file a written
request for an External Appeal.

We will provide an External Appeal application with the Final
Adverse Determination issued through Our internal review process,
or Our written wavier of any internal appeal.

You may also request an External Appeal application from New
York State at (1-800-400-8882. Submit the completed application
to State Department of Insurance at the address indicated on the
application. If you satisfy the criteria for an External Appeal, the
State will forward the request to a certified External Appeal Agent.

You will have an opportunity to submit additional information with
your request. If the External Appeal Agent determines that the
information you submit represents a material change from the
information on which We based Our denial, the External Appeal
Agent will share this information with Us in order for Us to exercise
Our right to reconsider Our decision. If We choose to exercise this
right, We will have three business days to amend or confirm Our
decision. Please note that in the case of an Expedited Appeal
(described below), We do not have the right to reconsider Our
decision.

In general, the External Appeal Agent must make a decision within
30 days of receipt of your completed application. The External
Appeal Agent may request additional information from you, your
physician or Us. If the External Appeal Agent requests additional
information, they will have five additional business days to make
its decision. The External Appeal Agent must notify you in writing
of its decision within two business days.

Expedited External Appeal

If your attending physician certifies that a delay in providing the
service that has been denied poses an imminent or serious threat
to your health, you may request an Expedited External Appeal. In
that case, the External Appeal Agent must make a decision within
three days of the receipt of your completed application.
Immediately after reaching a decision, the External Appeal Agent
must try to notify you and Us by telephone or facsimile of that
decision. The External Appeal Agent must also notify you in writing
of its decision.

If the External Appeal Agent overturns Our decision that a service
is not Medically Necessary or approves coverage of an
experimental or investigational treatment, We will provide coverage
subject to the other terms and conditions of this Certificate. Please
note that if the External Appeal Agent approves of an experimental
or investigational treatment that is part of a clinical trial, We will only
Cover the costs of services required to provide treatment to you
according to the design of the trial. We shall not be responsible for
the costs of investigational drugs or devices; the costs of non-
health care services, the costs of managing research, or the costs,
which would not be Covered under this Certificate for non-
experimental or non-investigational treatments provided in such
clinical trial.

The External Appeal Agents decision is binding on both you and
Us. The External Appeal Agents decision is admissible in any
court proceeding.

We will charge you a fee of $50 for an external appeal. The
External Appeal application will instruct you on the manner in which
you must submit the fee.

We will also waive the fee if We determine that paying the fee
would pose a hardship to you. If the External Appeal Agent
overturns the denial of coverage, the fee shall be refunded to you.

E. YOUR RESPONSIBILITIES

It is your RESPONSIBILITY to initiate the External Appeal
process. You may initiate the External Appeal process by filing a
completed application with the New York State Department of
Insurance. An insured, the insureds designee and, in connection
with a retrospective adverse determinations, an insureds health
care provider, shall have the right to request External Appeal.

Under New York State law, your completed request for an Appeal
must be filed within 45 days of either the date upon which you
receive written notification from Us that We have upheld a denial of
coverage during the internal Appeal process or the date upon
which you receive a written wavier of any internal Appeal. We have
no authority to grant an extension to this deadline.

Employee Retirement Income Security Act (ERISA) Rights

After all levels of Appeals have been completed, the Member may
have the right to file a civil action under 502(a) of the Employee
Retirement Income Security Act. ERISA rights do not apply if the
Members coverage for health benefits was:

1. Obtained through employment with a church or government
group; or

2. Purchased as an individual plan from Oxford.

Section VII.
Ter mi nat i on of Cover age

1. How Your Coverage May Terminate

Your Coverage under this Certificate will terminate:

A. Where permitted by the Group, upon written notice from
you. If you provide written notice at least 15 days prior to the
beginning of the following month, coverage will terminate on the
last day of the month in which notice is given. If 15 days notice is
not received, coverage under this provision will not terminate until
the end of the following month. Please Note: This provision is not
available if the Group pays 100% of the Premium.

B. Upon termination of the Agreement. Either We or the Group
can terminate the Agreement under certain conditions. Coverage
will cease at 11:59 midnight on the date the Agreement terminates.
We are not obligated to notify you that your coverage under this
Plan is being terminated. The Group will provide you with this
notice. The fact that you did not receive notice from Us will not
continue or extend your coverage under this Plan beyond the date
of the Agreement.

C. Upon loss of eligibility. Your coverage will cease on the date
you no longer meet the eligibility requirements of your Group or the
requirements of this Certificate regarding eligibility for coverage.
When a Subscriber loses eligibility, his or her Covered Dependents
will also become ineligible on that date.

D. For cause, if you:

1. repeatedly refuse to pay a required Copayment or Coinsurance
to a Network Provider;

2. Threaten the life of, and/or otherwise threaten to commit (or
commit) an act of violence against: an Oxford employee, Oxford
property, a Network Provider or member of his or her staff, or the
property of an Network Provider.

3. do not cooperate with the Us by failing to provide information
regarding other coverages, or providing releases, assignments and
other documents as may be requested for reimbursement under
COB, Workers' Compensation, Medicare or automobile insurance,
or as otherwise required for the administration of the Plan by this
Certificate;

4. have permitted your Identification Card to be used improperly.
We will not be responsible for the cost of any Covered Services
obtained through the misuse of the card and We have the right to
recover any expenditures incurred as a result of the misuse of the
Identification Card. A Member's misuse of his or her Identification
Card will not result in termination of coverage for the Member's
entire family unless the Member is the Subscriber;

5. have made a material misrepresentation to Us in your
application. In this instance, We will rescind coverage and you will
be responsible for the costs of all services received. No statement
made for the purpose of obtaining coverage will result in recission
of coverage unless the statement is contained in the application
and a copy has been provided to you prior to termination;

6. have made a material misrepresentation to Us (other than in
your application), or have committed a fraud against Us. We will
terminate coverage upon written notice. We have the right to
recover any expenditures incurred on or after the date of the
misrepresentation or fraud. No statement will be used to terminate
coverage unless it is in writing and signed by the Subscriber or
Member. All statements made by any Member or any person
applying for coverage under this Certificate will be deemed
representations, not warranties;

Coverage will not be terminated on the basis of your health status
or health care needs. Exercising your Grievance rights will not
result in the termination of coverage.

2. Effective Date of Termination

If you have been terminated for cause (subsection D. above), We
will notify you of the termination in writing. All terminations are
effective 31 days from the date the notice is mailed.
3. Reinstatement

A Member will not be reinstated automatically if Coverage is
terminated.

Re-application is required.

Section VIII.
What Happens I f I Lose
Cover age?

1. Termination or Loss of Eligibility: Coverage
Options

I. COBRA

Federal law provides that, in certain cases, coverage may continue
under this Plan. The abbreviation for that law is COBRA. Electing
coverage under this provision ends any rights under any applicable
state continuation provision. The following is a summary of the
terms and conditions.

A. Continuation of Coverage for You and Your Covered
Dependents

If you and your Covered Dependents become ineligible under the
Certificate due to (a) termination of your employment for any
reason (except for gross misconduct on your part), or (b) a
reduction in your hours of employment, coverage may be continued
under this Certificate for you and/or your Covered Dependents,
subject to the following:

1. You and/or your Covered Dependents must elect to continue
such coverage and coverage by the Plan within the 60-day period
described in the Notice of Federal Continuation Rights given by the
Group to you and/or your Covered Dependents;

2. You and/or your Covered Dependents make the required
contributions;

3. You and/or your Covered Dependents are not entitled to
Medicare or covered under Medicare or any other group health
plan; and

4. You and/or your Covered Dependents comply with all other
terms and conditions under this Certificate.

The coverage under this subsection A. will end on the earliest of:

1. The last day of the 18-month period from the date you became
ineligible under the Certificate. This 18-month period may be
extended to a 29-month period for you or a Covered Dependent
who is and remains disabled as determined under Title II or XVI of
the Social Security Act;

2. The date any required contribution for a Member on COBRA is
not made;

3. The date any Member on COBRA becomes entitled for benefits
under Medicare;

4. The date any Member on COBRA becomes covered under
another group health plan without limitation or exclusion of
preexisting conditions; and

5. The date that coverage under this Certificate is discontinued
with respect to all employees of the Group.

B. Continuation of Dependent Coverage Only

Coverage under this Certificate may be continued for Covered
Dependents who become ineligible while Covered under this Plan.
In addition to your termination of employment or reduction in hours,
as described above in subsection 1, this provision applies when
your Covered Dependents lose eligibility for any of the following
reasons:

1. You die while providing coverage for your Covered Dependents
under this Certificate;

2. There is a divorce or legal separation from you; or

3. A Covered Dependent (other than spouse) ceases to be a
Covered Dependent as defined in the Certificate.

Newborns who are born while the Subscriber is on COBRA
Continuation and children placed in the Subscribers home for
adoption while the Subscriber is on COBRA Continuation, are
eligible for COBRA coverage. They must be enrolled in
accordance with the Certificates terms and conditions for
Dependent coverage.

To obtain coverage under this provision, the Member must: notify
the Group of the event; elect in writing to continue coverage within
the 60-day period described in the Notice of Federal Continuation
Rights; make the required contributions; and not be entitled to
Medicare or other Group coverage.

Coverage under this subsection B. will end on the earliest of:

1. The last day of the 36-month period from the date the Member
became ineligible under the Certificate;

2. The date any required contribution is not made;

3. The date the Member becomes entitled to benefits under
Medicare;

4. The date the Member becomes covered under any group health
plan without limitation or exclusion of preexisting conditions; or

5. The date coverage under this Certificate is discontinued with
respect to all employees of the Group.

C. Other COBRA Information

1. Coverage for Persons on COBRA Under a Prior Plan. You
or your Covered Dependent may have elected COBRA under a
prior plan. In such a case, this Plan will provide coverage for the
period remaining under COBRA subject to the termination
provisions described above, and all other terms and conditions of
this Certificate. Any time exhausted under the prior plan, whether
due to an extension of benefits or otherwise, will be deducted from
the length of time COBRA coverage is available under this
Certificate.

2. Increases and Decreases in Coverage. Any amount of
coverage or benefits continued under COBRA is subject to any
increases and reductions as set forth in Section II., "Increase or
Reduction in Benefits."

3. Notification Requirements

a. Election. The failure to elect coverage within the 60-day period
discussed above will result in the loss of the COBRA option.

b. Benefits. You or your Covered Dependents must notify the
Group no later than 60 days after any of the following events occur:

i. There is a divorce or legal separation between you and your
spouse;

ii. A child ceases to be a Covered Dependent as defined in this
document.

Failure to provide this notice will result in the loss of the COBRA
option.

c. Disability. If coverage for you or your Covered Dependents is
being continued for 18 months under Section A. above and it is
determined that you or your Covered Dependent was disabled (as
determined under Title II or XVI of the Social Security Act) either
before or during the first 60 days of coverage under Section A, you
or your Covered Dependent must notify the Group of such
determination within 60 days after the date of the determination (if
you or your Covered Dependent wishes to receive 29 months of
COBRA coverage). The Group must also be notified within 30 days
after the date of any final determination that you or your Covered
Dependent is no longer disabled.

4. Payment Requirements

You or your Covered Dependents must pay for COBRA coverage.
Payments are made on a monthly basis and must be paid to the
Group in advance (in some instances, payment will be sent directly
to Us). The first payment must be sent with the election notice to
the Group.

5. Multiple Continuation Periods

If a Covered Dependent is on an 18-month continuance under
Section A, and one of the events listed in Section B occurs,
coverage can be extended. Coverage for up to 36 months is
available, measured from the date that coverage under Section A
began. Any extended coverage is subject to all other terms of the
Certificate.

6. Maximums, Deductibles and Copayments

a. Any benefit maximums as well as any other limits on benefits
under COBRA will be reduced by any corresponding amounts or
limitations previously paid or satisfied, whether in whole or in part
under this Certificate on the date before you became ineligible
under this Certificate.

b. Any Copayments paid for the Contract Year under this
Certificate before you became ineligible under this Certificate will
be applied toward the satisfaction of the Copayment limit for that
Contract Year.

7. Conversion

The conversion privilege described in Conversion Privilege
section below is available to Members upon termination of COBRA.

II. State of New York Continuation

If the Group is not subject to COBRA, continuation as required by
the State of New York ("State Continuation") may be available as
described below. Please note: A Member is not eligible for State
Continuation if he or she:

Is eligible for COBRA;

Is covered or could be covered by Medicare; or

Is covered or is eligible for coverage under another group
health plan (either as an employee or dependent), regardless
if the plan is insured or uninsured but only if such health plan
does not contain an exclusion or limitation with respect to a
Member's pre-existing condition.

Dependents

If a Member's coverage under this Certificate would end because
the Subscriber:

has terminated employment ; or

has become a member of a class of employees who are not
eligible for coverage the Member and/or Covered Dependents
may apply for State Continuation. Members who wish to elect
State Continuation must request the coverage, in writing,
within the 60-day period following the later of: the date of the
termination or ineligibility; or the date the Member is given
notice by the Group.

The coverage under this subsection A. will end on the earliest of:

1. Eighteen months after the date the Member became ineligible
under the Certificate. This 18-month period may be extended to a
29-month period for a Member who is and remains disabled as
determined under Title II or XVI of the Social Security Act;


3. The date any Member becomes covered or eligible for coverage
under Medicare;

4. The date any Member becomes covered or eligible for coverage
under another group health plan (as either a subscriber or
dependent) unless that plan restricts coverage of a pre-existing
condition of the Member; or

5. The date that coverage under this Certificate is discontinued
with respect to all employees of the Group.

B. Continuation of Dependent Coverage Only

Coverage under this Certificate may be continued for Covered
Dependents who become ineligible while Covered under this
Certificate. This provision applies only when your Covered
Dependents lose eligibility for any of the following reasons:

1. You die while providing coverage for your Covered Dependents
under this Certificate;

2. There is a divorce or legal separation from you;

3. A Covered Dependent (other than spouse) ceases to be a
Dependent as defined in the Certificate.

Newborns who are born while the Subscriber is on COBRA
Continuation and children placed in the Subscribers home for
adoption while the Subscriber is on COBRA Continuation, are
eligible for COBRA coverage. They must be enrolled in
accordance with the Certificates terms and conditions for
Dependent coverage.

To obtain coverage under this provision, the Member must, in
writing, elect to continue coverage within the 60-day period
following the event qualifying them for coverage.

Coverage under this subsection B. will end on the earliest of:

1. The last day of the 36-month period from the date the Member
became ineligible under the Certificate;


3. The date the Member becomes eligible for benefits under
Medicare;

4. The date the Member becomes eligible for coverage under any
group health plan (either as a subscriber or dependent) unless that
plan restricts coverage of a pre-existing condition of the Member; or

5. The date coverage under this Certificate is discontinued with
respect to all employees of the Group.

C. Other State Continuation Information

1. Coverage for Members on State Continuation Under a Prior
Plan.

You or your Covered Dependents may have elected State
Continuation under the Group's prior plan. In such a case, this
Plan will provide coverage for the period remaining under State
Continuation subject to the termination provisions described above,
and all other terms and conditions of this Certificate. Any benefits
paid under the prior plan, whether due to an extension of benefits
or otherwise, will be deducted from benefits payable under this
Certificate.

2. Disability

If coverage for you or your Covered Dependents is being continued
for 18 months under Section A. above and it is determined that you
or your Covered Dependent was disabled (as determined under
Title II or XVI of the Social Security Act) either before or during the
first 60 days of coverage under Section A, you or your Covered
Dependent must notify the Group of such determination within 60
days after the date of the determination (if you or your Covered
Dependents want to receive 29 month of continuation coverage).
The Group must also be notified within 30 days after the date of
any final determination that you or your Covered Dependent is no
longer disabled.

3. Payment Requirements

You or your Covered Dependents must pay for State Continuation
coverage. Payments are made on a monthly basis and must be
paid to the Group in advance. The first payment must be sent with
the election notice to the Group.

4. Multiple Continuation Periods

If a Covered Dependent is on an 18-month continuance under
Section A, and one of the events listed in Section B occurs,
coverage can be extended. Coverage for up to 36 months is
available, measured from the date that coverage under Section A
began. Any extended coverage is subject to all other terms of the
Certificate.

5. Maximums, Deductibles and Copayments

a. Any benefit maximums as well as any other limits on benefits
under State Continuation will be reduced by any corresponding
amounts or limitations previously paid or satisfied, whether in whole
or in part under this Certificate on the date before you became
ineligible under this Certificate.

b. Any Copayments paid for the Contract Year under this
Certificate before you became ineligible under this Certificate will
be applied toward the satisfaction of the Copayment limit for that
Contract Year.

6. Conversion

The Conversion Privilege described below is available to Members
upon termination of their State Continuation.

III. Extended Benefits

1. Eligibility for Extended Benefits

If a Member is Totally Disabled on the date his or her coverage
under the Plan ends, the Plan will pay benefits only for those
Covered Services that are for the treatment of the particular injury
or sickness that is the cause of the Total Disability.

For purposes of this section, Total Disability means: a Subscriber
who is prevented because of injury or disease from performing his
or her regular or customary occupational duties and is not engaged
in any work or other gainful activity for pay or profit. A Covered
Dependent who is prevented because of injury or disease from
engaging in substantially all of the normal activities of a person of
like age and sex who is in good health.

2. Termination of Extended Benefits

Extended Benefits will end on the earliest of the following:

a. The date the Member is no longer Totally Disabled as
determined by the Member's Physician;

b. The date the contractual benefit limit has been reached;

c. Twelve months from the date coverage under the Extended
Benefits Provision began.

d. The date the Member becomes eligible for benefits under any
group policy providing medical benefits or services, or Medicare (if
allowed by law).

3. Limits on Extended Benefits

We will not pay Extended Benefits:

a. For any Member who is not Totally Disabled on the date his or
her insurance under this Certificate ends;

b. For any child born as the result of a pregnancy for which
benefits are being extended; and

c. Beyond the extent to which We would have paid benefits under
the Certificate if coverage had not ended.

Continuation of coverage under either COBRA or State of New
York Continuation is not available if Extended Benefits has been
elected or exhausted.

Conversion Coverage is not available once Extended Benefits has
been elected or exhausted.

IV. Conversion Privilege

In the event you cease to be eligible for coverage under this
Certificate, you may, within 45 days after termination of coverage
under this Certificate convert to individual membership. The
individual coverage will become effective as of the date of the
termination. In order to be eligible for conversion coverage, your
coverage, or the coverage of your Covered Dependents, must
terminate for one of the following reasons:

1. The Agreement between the Group and Us is terminated and
the Group does not replace the coverage provided by this
Certificate with continuous and similar coverage;

2. A Subscriber ceases to meet the eligibility requirements of this
Certificate. In this instance, the Subscriber and his or her then
Covered Dependents are eligible to convert;

3. A Covered Dependent ceases to meet the eligibility
requirements of this Certificate because of attaining the limiting
age, death of the Subscriber or divorce or annulment; or

4. Continuation of coverage under COBRA, or State Continuation
expires and the Member is not eligible for coverage under any
other group health plan or Medicare.

In order to be eligible for conversion coverage a Subscriber must
have been continuously Covered under this Certificate for at least
three months immediately prior to the termination;

Conversion coverage is not available if:

1. The Member is or is eligible to be covered for similar benefits
under: another group plan, medical services subscriber contract,
medical practice or other prepaid plan regardless of whether the
coverage is on an insured or self-funded basis; or any
governmental program and such coverage combined with the
conversion coverage would result in overinsurance (as defined by
Our overinsuance rules which are filed with the State).

2. Coverage was terminated for cause as described in the
"Termination of Coverage" section of this Certificate.

To obtain conversion coverage, you or your Covered Dependents
must do two things. First, you must submit a completed application
for conversion to Us within 45 days after the date of termination.
This 45-day period will be extended an for an extra 45 days (90
days total) if your employer does not give you timely notice of your
conversion rights. Finally, you must submit the required premium
payments. We will not ask for evidence of good health.

Please note that the premium under conversion will differ from that
under the Group coverage. In addition, the terms of the conversion
plan will be different. You or your Covered Dependents will be
issued the conversion plan that is being offered by Us at the time of
your application. This plan will offer benefits at the same level as
are available to Our conversion subscribers in general.

Application for conversion is not initiated by Us. You or your
Covered Dependents must initiate the application procedure. In
accordance with its usual notification procedures, the Group is
responsible for giving notice of your eligibility for conversion
coverage. However, if coverage under this Certificate has ended
due to the exhaustion of your or your Covered Dependents COBRA
coverage, the Group must give you notice of your conversion
rights. The Group must do this during the 180-day period prior to
the expiration of the COBRA coverage.

V. Other Available Coverage

1. Leave of Absence or Lay-off

If your coverage would terminate because you are temporarily laid-
off or receive an approved leave of absence, coverage may be
continued for up to 60 days, or as otherwise agreed upon by Group
and Us; if Group: (1) pays the Premium for the continued
coverage; and (2) requires all participating carriers to provide
continued coverage to employees whose coverage would
otherwise terminate because of a temporary lay-off or approved
leave of absence.

2. Family and Medical Leave Act

Federal law provides that certain employees can take up to 12
weeks of unpaid leave in a 12-month period for the birth or
adoption of a child, or for a serious health condition affecting the
employee or a family member. Employers subject to this law are
required to keep an employee's medical coverage in force to the
same extent as if no leave had been taken. Your obligations,
including any Premium contributions and compliance with Plan
provisions, do not change during a leave.

If your employer is subject to this law, and you are eligible for leave
under the Act, We will continue your coverage during a qualified
leave. Coverage will terminate for failure to comply with Plan
provisions, including the failure to pay Premium. You should check
with your employer regarding family or medical leaves.

Section IX.
What Happens I f a
Pr ovi der Bi l l s Me?

1. Filing a Claim

You are financially responsible for the cost of any Covered
Services received from non-Network Providers unless those
services were either Precertified by Us or were required to treat a
Medical Emergency or Urgent Care situation as described in this
Certificate.

In order to be reimbursed, you must complete a claim form, sign it,
and send it to Us with the original, itemized bill(s). Only original
bills will be considered. Itemized bills should contain:

Patient name
Type of service
Name and address of provider making the charge
CPT-4 codes, or HCPCS codes (description of services)
Date of service
Individual charge for each service
ICD-9 codes (diagnosis or symptoms)

Be sure to keep a copy of your claim form and bills for your own
records.

Claim forms are available from the Group or from Us by calling the
Customer Care telephone number listed in the front of this
Certificate. Completed forms should be sent to the address listed
for "Claims" at the front of this Certificate.

2. Payment options

You may request Us to make payment directly to you or to the
provider. If you want Us to pay the provider directly (referred to as
assignment), you must give the provider a blank claim form to be
completed and forwarded with the itemized bill.

If you decide to pay a provider directly, submit the completed claim
form with your bill to Us for reimbursement as described above.
Although We will generally follow your instructions, We reserve the
right to make the final determination.

3. Limitations

All requests for reimbursement must be made within 90 days of the
date Covered Services were rendered. Failure to request
reimbursement within the required time will not invalidate or reduce
any claim if it was not reasonably possible to provide such proof
within the 90-day period. However, such request must be made as
soon as reasonably possible thereafter.

All reimbursements to non-Network Providers are subject to UCR
unless you were referred to a non-Network Provider by Us.

4. If You Receive a Bill From a Network
Provider

The cost of Covered Services provided by Network Providers in
accordance with the terms of this Certificate will be billed directly to
Us. No claim forms are necessary.

If you should receive a bill from a Network Provider for Covered
Services, please contact the Member Service Department
immediately.

5. Claim Information

Claims for Covered Services will be paid within 45 days after We
receive proof of claim and all of the information we need to process
the claim. If necessary, Our Claims Department will contact you for
more information regarding your claim in order to speed up the
processing. If you would like to inquire about the status of a claim,
call the "Claims" telephone number list in the front of this
Certificate. Please have the date of service and your ID number
ready.

6. Physical Examination

We have the right and the opportunity to examine the Member who
is the basis of any claim at all reasonable times while the claim is
pending. This will be done at Our expense.

Section X.
Ot her I mpor t ant
Doc ument s

1. Supplemental Coverage by Rider

The terms and conditions of this Certificate are subject to revision,
addition or deletion. Any such changes will be made by rider. The
terms of a rider that is issued by Us and accepted by the Group will
supersede conflicting terms in this Certificate. Riders that are part
of your Plan will be issued with your Certificate. However, you may
want to verify with the Group whether your Plan is subject to any
rider.

Please check with your Benefits Administrator to make sure you
have the most recent documents concerning your supplemental
coverage under the Plan.

2. Summary of Benefits

In order to receive Covered Services under this Certificate, We may
require that you pay a Copayment or Coinsurance to the Network
Provider who supplied the Covered Services. In addition, certain
other charges may be applied. You will receive a Summary of
Benefits that will explain all of the applicable Copayments and
Coinsurance as well as other similar features of your Plan. It will
also list specific limitations on visits, days and dollar amounts for
the benefits that are provided by the Plan.

Please check with your Benefits Administrator to make sure you
have the most recent Summary of your coverage under the Plan.

3. Living Wills and Advance Directives

You have the right to participate in decisions relating to your health
care. Working with your doctor, you can decide whether to accept
or reject proposed medical treatments. That right extends to
situations where, because of your medical condition, you are
unable to communicate with your doctor or the hospital. This is
done by the creation of an Advance Directive.

An Advance Directive is a written, signed document, that provides
instructions for your care if you are unable to communicate your
wishes directly. Depending on the state where you reside or are
receiving treatment, the most common forms of Advance Directives
are Living Wills and Durable Powers of Attorney. These
documents instruct your health care providers how to proceed if
you are not able to communicate with them.

Additionally, The New York State Health Care Proxy Law allows an
adult to designate another adult, such as a trusted friend or loved
one who knows the person and his or her wishes, to make these
treatment decisions if the adult becomes incapacitated and is
unable to do so.

If you decide to execute an Advance Directive or Proxy, you should
notify all of your regular providers. In addition, you should have
some way of notifying police and emergency medical personnel
that you have made an Advance Directive. For example, you may
want to keep a card in your wallet or purse.

You are not required to make an Advance Directive or a Proxy. If
you do decide to make one, please note that you are free to amend
or cancel it at any time.

Section XI.
Member Ri ght s and
Responsi bi l i t i es

What Are My Rights as a Member?

As a Member you have the following rights:

1. The right to obtain complete and current information concerning
a diagnosis, treatment and prognosis from any Network Provider in
terms that you or your authorized representative can readily
understand. You have the right to be given the name, professional
status and function of any personnel delivering Covered Services to
you.
You also have the right to receive all information from a Network
Provider necessary for you to give your informed consent prior to
the start of any procedure or treatment.

Finally You have the right to refuse treatment to the extent
permitted by law. We and, when appropriate, your Network
Provider will make every effort to arrange a professionally
acceptable alternative treatment. However, if you still refuse the
recommended treatment and We and your Network Provider
believe no professionally acceptable alternative exists, We will not
be responsible for the cost of further treatment for that condition.
You will be notified accordingly.

2. The right to be provided with information about Our services and
medical providers that accurately provides relevant information in a
manner that is easily understood.

3. The right to quality health care services, provided in a
professional and respectful manner. You also have the right to
participate in decision-making regarding your health care.

4. The right to privacy and confidentiality of your health records,
except as otherwise provided by law or contract. You have the
right to all information contained in your medical records unless
access is specifically restricted by the attending physician for
medical reasons.

5. The right to initiate disenrollment from the plan.

6. The right to file a formal grievance if complaints or concerns
arise about Our medical or administrative services or policies.

7. You have, when Medically Necessary, the right to emergency
care without unnecessary delay.

8. You have the right to be advised if any of the Network Providers
participating in your care propose to engage in or perform human
experimentation or research affecting your care or treatment. You
or a legally responsible party on your behalf may, at any time,
refuse to participate in or to continue in any experimentation or
research program to which you have previously given informed
consent.

9. You have the right to sign language interpreter services in
accordance with applicable laws and regulations, when such
services are necessary to enable you, as a person with special
communication needs, to effectively communicate with your
Network Provider.

Should you have any difficulty in arranging for such services,
please contact your Oxford Customer Care Representative. We
can also arrange for TTY services. To receive payment for such
service(s), please have your Network Provider mail Us an invoice
from the translation service.

What Are My Responsibilities?

Your Responsibilities Include:

1. To enter into this Plan with the intent of following the policies
and procedures as outlined in this Certificate.

2. To take an active role in your health care through maintaining
good relations with your Network Providers and following
prescribed treatments and guidelines.

3. To provide, to the extent possible, information that a
professional staff needs in order to care for you as a Member.

4. To use the emergency room only as described in this Certificate.

5. To notify the proper Plan representative of any change in name,
address or any other important information.

Section XII.
Gener al Admi ni st r at i ve
Pol i c i es and Pr oc edur es

1. Medical Records: Confidentiality and
Authorization to Examine

Your medical records are confidential documents. Access to those
records will be limited to persons who need to see them. They will
be used to determine appropriate medical care for you, to
administer this Plan, and in some cases, to meet state and federal
regulatory requirements. Your records will not be released for any
other reason without your authorization. By participating in the
Plan, you agree and authorize Us, Network Physicians, other
Network Providers and non-Network Providers to permit the
examination and copying of any portion of your Hospital or medical
records, when requested by Us for the reasons discussed above.

Additionally, Oxford has the right, without authorization of the
Member or Group, to review, including but not limited to; medical
records, enrollment records and other information needed to verify
services if potential fraud is suspected.

If you would like a copy of Our Notice of Privacy Practices please
contact Us at the address provided for Managed Care Act requests
(in the Getting Started section of this Certificate.) or log on to Our
website, www.oxfordhealth.com.

2. Coordination of Benefits (COB)

A Member may be covered by two or more plans at the time that
Covered Services are rendered. In determining what benefits are
payable under this Certificate, We will do the following:

First: We will provide the Covered Services required. Then, as
permitted by law, We will take into account any other coverages.
These other coverages are plans that provide medical, dental or
prescription drug benefits or services, including but not limited to:

A. Any group insurance, prepaid health plans, or any other insured
or uninsured arrangement of group coverage.

B. Where permitted by state law, any automobile insurance
contract, pursuant to any federal or state law, which mandates
indemnification for medical services to persons suffering bodily
injury from motor vehicle accidents, but only if:

a. Covered Services are eligible for payment under the provisions
of such policy; and

b. the policy does not, under its rules, determine its benefits after
the benefits of any group health insurance.

Please note: This Plan does not coordinate benefits with itself.

Second: If there is other coverage, We will calculate the Allowable
Expense. The Allowable Expense is any necessary, reasonable,
and customary item of expense that is at least partly covered under
one or more of the plans covering the Member.

When a plan provides services, instead of paying cash, the value of
each service rendered will be considered to be both: an Allowable
Expense and a benefit paid.

Third: We will determine the amount We will pay. We will pay the
lesser of: Our regular benefits or a reduced amount. The reduced
amount will only be paid when there is other coverage in effect, and
the benefit under the other coverage plus the coverage under this
Certificate equals 100% of the Allowable Expense.

In determining Our coverage, We will determine the order in which
the various coverages will pay. Order of payment is determined
using the following rules:

A. A plan with no COB provisions, or provisions that do not comply
with applicable state law, will be considered to pay its benefits
before a plan that contains such a provision.

B. A plan that covers a person as a Subscriber will be considered
to pay its benefits before a plan that covers that person as spouse
or dependent.

C. When a Member is covered under two or more plans as a
dependent, We will compare the month and day of the birthday of
each parent who is providing the coverage. The plan of the
employee who has the earliest birth date will be considered to pay
first. When both parents have the same birth date, the plan that
has provided coverage the longest will be considered to pay first. If
the COB rules of any plan do not use the birth date to determine
coverage, the procedures described in that plan will be used.

When the parents of the dependent are divorced or separated, the
following rules will apply:

1. In some cases there will be a court decree that orders one of the
parents to provide coverage. If that parent's plan covers the
individual as a dependent, and the plan has actual notice of the
decree, that plan will be considered to pay first.

If 1. does not apply, then:

2. The custodial parent's plan which covers the child as a
dependent will be considered to pay before any other dependent
coverage.

3. The plan that covers the custodial parent's spouse and which
covers the child as a dependent will be considered to pay before
any other dependent coverage.

4. If 1.- 3. above do not apply, the plan that covers the child as a
dependent of the parent without custody will be considered to pay
benefits first.

D. A plan that covers a person as an active employee (or that
employee's dependent) pays before a plan that covers a person as
laid-off or retired employee (or that employee's dependent). If the
other plan does not have the provision discussed in the previous
sentence, it will not apply.

E. If A, B, C, and D above fail to establish the order of payment,
the plan that has covered the person the longest will be treated as
paying benefits first.

We have the right to release or obtain any information and make or
recover any payments that We consider necessary to administer
this provision. We may obtain information necessary to administer
this provision without your consent or notice to you. You agree to
provide Us with any information or cooperation We need to
administer this provision.

If payments that We are required to make under this Certificate are
made by another plan, We may be required by this provision to
reimburse that plan. Amounts paid in this manner are deemed to
be benefits paid under this Certificate and, to the extent of those
payments, We are fully discharged from liability under this
Certificate.

If we make payments in excess of Our obligations under this
provision, We have the right to recover any excess from one or
more of the following: any person, any other insurance company or
any other organization.

Please note, that failure to cooperate with Us regarding this
provision could subject you to all charges for Covered Services
subject to this provision. Failure to cooperate is grounds for
termination of coverage.

3. Effect of Coordination

When this Plan is secondary, the benefits of this Plan will be
reduced so that the total benefits paid by the primary plans(s) and
this Plan will not exceed our maximum available benefit for each
Covered Service under the Certificate. Also, the amount paid or
provided will not be more than the amount we would pay or provide
if we were primary.

We will coordinate benefits with plans, whether insured or self-
insured, which provide benefits which are stated to be always in
excess or always secondary or use order of benefit determination
rules which are inconsistent with those described above (non-
complying plans) in the following manner:

a. If this Plan is primary, We will pay or provide benefits first.

b. If this Plan is secondary, We will pay only the amount we would
pay or provide as the secondary insurer.

c. If We request information from a non-complying plan and do not
receive it within 30 days of our request, We will calculate the
amount We should pay or provide on the assumption that the non-
complying plan and contract provide identical benefits. When the
information requested is received, We will make any necessary
adjustments.

4. Reimbursement and Subrogation

Reimbursement

This section applies when a Member recovers damages, by
settlement, verdict or otherwise (in which sums for medical
expenses have been specifically identified), for an injury, sickness
or other condition. If the Member has made, or in the future may
make, such a recovery, including a recovery from any insurance
carrier and We have paid for or provided benefits, the Member, or
the Members legal representatives, estate or heirs must promptly
reimburse Us for the reasonable value of the medical benefits paid
for or provided by Us to the Member.

In order to secure Our rights under this section, the Member must
assigns to Us any benefits the Member may have under any
automobile policy or coverage, to the extent of Our claim for
reimbursement. The Member must sign and deliver, at Our request
or Our agents, any documents needed to effect such assignment of
benefits.

The Member must cooperate with Us and Our agents and must:
sign and deliver such documents as We or Our agents reasonably
request to protect Our right of reimbursement; provide any relevant
information; and take such actions as We or Our agents reasonably
request to assist Us in making a full recovery of the reasonable
value of the benefits provided. The Member shall not take any
action that prejudices Our right of reimbursement.

We shall be responsible only for those legal fees and expenses to
which We agree to in writing.

If the Member fails to cooperate with Us, the Member will be
responsible to repay Us the amount of the benefits We have paid.

Subrogation

This section applies when another party is, or may be considered,
liable for a Members injury, sickness or other condition (including
insurance carriers who are so liable) and We have provided or paid
for benefits.

In the event that you suffer an injury or illness for which another
party may be responsible, such as someone injuring you in an
accident, and We pay benefits as a result of that injury or illness,
We will be subrogated and succeed to the right of recovery against
the party responsible for your illness or injury to the extent of the
benefits We have paid. This means that We have the right
independently of you to proceed against the party responsible for
your injury or illness to recover the benefits We have paid

The costs of Our legal representation in matters related to
subrogation shall be borne solely by Us. The costs of legal
representation of the Member shall be borne solely by the Member.

5. Workers Compensation

Injuries and diseases covered under any Worker's Compensation
program are excluded from coverage under this Plan.

6. Medicare and Other Government Programs

This Plan is not intended to duplicate any coverage for which
Members are, or could be eligible for, such as Medicare or any
other federal or state government programs. Any benefits payable
under any such programs for Covered Services provided or
benefits paid under this Certificate shall be payable to and retained
by Us. You agree to complete and submit to Us any
documentation reasonably necessary for Us to receive or assure
reimbursement under Medicare or any other government programs
for which you or your Covered Dependents are eligible.

Benefits for Medicare Eligibles Who are Covered Under this
Certificate

1. If your Group has 20 or more employees, any active employee
or spouse of an employee who becomes or remains a member of
the Group Covered by this Certificate, after becoming eligible for
Medicare due to reaching age 65, will receive the benefits of this
Certificate as primary unless such Subscriber elects Medicare as
his or her primary coverage. However, the Subscriber must notify
Us of the election by signing and submitting to Us and election card
which indicates his or her choice. He or she must also pay any
required premium. Any Subscriber who elects Medicare as primary
shall not be eligible for coverage under this Certificate as of the
date of election.

2. If your Group has 100 or more employees or your group is an
organization which includes an employer with 100 or more
employees, any active employee, spouse of an active employee or
Dependent child of an active employee who becomes or remains a
member of the Group Covered under this Certificate, after
becoming eligible for Medicare due to disability, will receive the
benefits of this Certificate as primary unless the Subscriber elects
Medicare as his or her primary coverage. However, the Subscriber
must notify Us of his or her election by signing an election card
which indicates his or her choice. He or she must also pay any
required premium. Any Subscriber who elects Medicare as primary
will not be eligible for coverage under this Certificate as of the date
of this election.

3. Any Subscribers who are not subject to subsections 1. and 2. of
this Section and who are Medicare eligible will receive the benefits
of this Certificate reduced by any benefits available under Medicare
Part A and B. This applies even if the Subscriber fails to enroll in
Medicare or does not claim the benefits available under Medicare.

Section XIII.
Gener al Pr ovi si ons

1. Entire Agreement. This Certificate, Summary of Benefits, any
Certificate riders issued by the Us and accepted by the Group, the
Group Enrollment Agreement, and the individual applications of you
and your Covered Dependents, if any, constitute the entire contract
between the parties, and as of the effective date, supersede all
other agreements between the parties. Any and all statements
made to Us by the Group and any Subscriber or Covered
Dependent will, in the absence of fraud, be deemed
representations and not warranties, and no such statement, unless
it is contained in a written application for coverage under this
Certificate, shall be used in defense to a claim under this
Certificate.

2. Form or Content of Certificate. No agent or employee of Us is
authorized to change the form or content of this Certificate. Such
changes can be made only through an endorsement authorized
and signed by one of Our officers.

3. Identification Cards. The cards We issue to Members
pursuant to this Certificate are for identification only. Possession of
an identification card confers no right to Covered Services or other
benefits under this Certificate. To be entitled to such services or
benefits the holder of the card must, in fact, be a Member on whose
behalf all applicable Premiums under this Certificate have actually
been paid. Any person receiving services or other benefits to
which he is not then entitled pursuant to the provision of this
Certificate will be liable for the actual cost of such services or
benefits.

4. Notice. Any notice required under this Certificate may be given
to Us by U.S. Mail, first class, postage prepaid to the Customer
Care address listed in the front of the Certificate. Notice to a
Member will be sent to the last address We have for that Member.
Member agrees to provide Us with notice, within 31 days, of any
change of address.

5. Interpretation of Certificate. The laws of the State of New
York shall be applied to interpretations of this Certificate.

6. Assignment. This Certificate is not assignable by Group
without Our written consent. Any benefits under this Certificate are
not assignable by any Member without Our written consent. In
addition, This Agreement shall not confer any rights or obligations
on third parties except as specifically provided herein.

7. Gender. The use of any gender in this Certificate is deemed to
include the other gender and, whenever appropriate, the use of the
singular is deemed to include the plural (and vice versa).

8. Modifications. By this Certificate, the Group makes Our
coverage available to Members who are eligible under the terms of
the Certificate. However, this Certificate is subject to amendment,
modification, and termination in accordance with this provision, the
Group Enrollment Agreement or by mutual agreement between Us
and Group's Board of Directors without the consent or concurrence
of any Member. By enrolling in this Plan, all Members legally
capable of contracting, and the legal representatives of all
Members incapable of contracting, agree to all its terms, conditions,
and provisions.

9. Clerical Error. Clerical error, whether by the Group or Us, with
respect to this Certificate, or any other documentation issued by Us
in connection with this Certificate, or in keeping any record
pertaining to the coverage hereunder, will not modify or invalidate
coverage otherwise validly in force or continue coverage otherwise
validly terminated.

10. Policies and Procedures. We may adopt reasonable
policies, procedures, rules and interpretations to promote the
orderly and efficient administration of this Certificate with which
Members shall comply.

11. Waiver. The waiver by any party of any breach of any
provision of the Agreement will not be construed as a waiver of any
subsequent breach of the same or any other provision. The failure
to exercise any right hereunder will not operate as a waiver of such
right.

12. Termination of the Agreement. The Agreement will continue
in effect for the period of time specified in the Agreement, and may
be canceled in accordance with the terms of the Agreement.

13. Incontestability. Except as to a fraudulent misstatement: No
statement made by the Group or any Member will be the basis for
voiding coverage or denying coverage or be used in defense of a
claim unless it is in writing. No statement made by the Group will
be the basis for voiding the Agreement after it has been in force for
two years from its effective date.

14. Significant Change in Circumstances. If We are unable to
arrange for Covered Services as provided under this Certificate as
the result of events outside of Our control, We will make a good
faith effort to make alternative arrangements. These events would
include a major disaster, epidemic, the complete or partial
destruction of facilities, riot, civil insurrection, disability of a
significant part of Network Providers' personnel or similar causes.
We will make reasonable attempts to arrange for Covered
Services. We and Our Network Providers will not be liable for
delay, or failure to provide or arrange for Covered Services if such
failure or delay is caused by such an event.

15. Independent Contractors. Network Providers are
independent contractors. They are not Our agents or employees.
We and Our employees are not the agent or employee of any
Network Provider. We are not liable for any claim or demand on
account of damages arising out of, or in any manner connected
with, any injuries alleged to be suffered by any Member while
receiving care from any Network Provider or in any Network
Provider's facility.

16. Legal Action. No action at law or in equity may be maintained
against Us for any expense or bill unless brought within the statute
of limitations for such cause of action.

17. Hold Harmless. Network Providers have contractually agreed
that Members will not be held financially liable for any sums owed
to Network Providers for Covered Services (with the exception of
required Copayments, Coinsurance and Deductibles) in the event
that We fail to pay for Covered Services.

18. Application of Deductibles, Limitations and Maximums.
Calculations of annual deductibles, benefit limitations, out-of-pocket
maximums and lifetime maximums under this plan, will take into
consideration as applicable payments made by you and benefits
provided by Us and/or Our affiliate, Oxford Health Plans
(NY), Inc. (collectively Oxford), pursuant to any Group Enrollment
Agreement between Group and Oxford.

Section XIV.
Def i ni t i ons

Defined terms will appear capitalized throughout the Agreement.

Acute: The sudden onset of disease or injury, or a sudden change
in the Member's condition that would require prompt medical
attention.

Agreement: The Group Enrollment Agreement between Oxford
Health Insurance, Inc. and the Group including any attachments
and this Certificate.

Ambulatory Surgical Centers: A facility currently licensed by the
appropriate state regulatory agency for the provision of surgical and
related medical services on an outpatient basis.

Certificate: this Certificate of Coverage issued by Oxford Health
Insurance, Inc., including the Summary of Benefits and any
attached riders.

Coinsurance: The percentage of charges for Covered Services
that you are required to pay to a Provider.

Contract Year: that 12-month period commencing on the effective
date of the Agreement or any anniversary date thereafter, during
which the Agreement is in effect.

Copayment: The amount you are required to pay directly to a
Network Provider at the time Covered Services are rendered.

Cover, Covered or Covered Services: The Medically Necessary
services paid for or arranged for you by Us under the terms and
conditions of this Certificate.

Covered Dependents: Dependents, as defined in this Certificate,
who are Members.

Deductible: The amount specified in your Summary of Benefits
that you are responsible for before benefits are payable under this
Certificate.

Dependents: Your spouse, unmarried and newborn children as
described in the "Eligibility" section of this Certificate.

Enrollment Date: The Enrollment Date is the Member's first day
of coverage under the Certificate or, if earlier, the first day of the
waiting period that must pass with respect to the Member before
the Member is eligible to be Covered under the Plan.

Enrollment Form: Our form which Members must complete to
enroll in the Plan.

External Review Agent: An entity that has been certified by the
Commissioner of the State of New York Department of Health to
perform external reviews in accordance with New York law.

Group: The employer or party that has entered into an Agreement
with Us.

Group Open Enrollment Period: A period of time, established by
Group and Us, during which eligible persons may be enrolled.
Your employer or plan sponsor will have the dates for each period.

Homebound: A Member will be considered to be Homebound if
he or she has a condition due to an illness or injury which restricts
his or her ability to leave their place of residence except with the
aid of supportive devices such as crutches, canes, wheelchairs and
walkers; the use of special transportation; or the assistance of
another person. Additionally, a Member will be considered
Homebound if the Member has a medical condition where leaving
the home is medically contraindicated.

Home Health Care Agency: An organization currently certified or
licensed by the State of New York which has entered into an
contract with Us to render home health services.

Hospital: An institution rendering inpatient and outpatient services
for the medical care of the sick or injured. It must be accredited as
a Hospital by either the Joint Commission on Accreditation of
Health Care Facilities or the Bureau of Hospitals of the American
Osteopathic Association. A Hospital may be a general, acute care,
or a specialty institution, provided that it is appropriately accredited
as such, and currently licensed by the proper state authorities.

Medical Emergency: A medical or behavioral condition the onset
of which is sudden, that manifests itself by symptoms of sufficient
severity, including severe pain, that a prudent layperson,
possessing an average knowledge of medicine and health, could
reasonably expect the absence of immediate medical attention to
result in (a) placing the health of the afflicted Member with such a
condition in serious jeopardy, or in the case of a behavioral
condition placing the health of such Member or others in serious
jeopardy; (b) serious impairment to the Members bodily functions;
(c) serious dysfunction of any bodily organ or part of such Member;
or (d) serious disfigurement of such Member. Medical Emergencies
include, but are not limited to, the following conditions:

Severe chest pains
Severe or multiple injuries
Severe shortness
Loss of consciousness of breath
Sudden change in mental status
Severe bleeding (e.g., disorientation)
Acute pain or conditions
Poisonings or convulsions requiring immediate attentionsuch
as suspected heart attack or appendicitis

Medically Necessary: Services or supplies as provided by a
Hospital, Skilled Nursing Facility, Physician or other provider
required to identify or treat your illness or injury and which, as
determined by Our Medical Director, are:

1. Consistent with the symptoms or diagnosis and treatment of
your condition;

2. Appropriate with regard to standards of good medical practice;

3. Not solely for your convenience or that of any provider; and

4. The most appropriate supply or level of service which can safely
be provided. For inpatient services, it further means that your
condition cannot safely be diagnosed or treated on an outpatient
basis.

Unless otherwise indicated in this Certificate, determinations as to
Medical Necessity are made by Us, and such determinations are
solely within Our discretion.

Medicare: Title XVIII of the Social Security Act, as amended.

Member: Subscribers and Covered Dependents for whom
required Premiums have been paid. Whenever a Member is
required to provide a notice pursuant to a grievance or emergency
room visit or admission, Member also means the Members
designee.

Network Physician: A Physician who, at the time of providing or
referring Covered Services, is contracted with Us to provide
Covered Services to Members.

Network Provider: A Physician, Certified Nurse Midwife, Hospital,
Skilled Nursing Facility, Home Health Care Agency, or any other
duly licensed or certified institution or health professional under
contract with Us to provide Covered Services to Members. A list of
Network Providers and their locations is available to you upon
enrollment or upon request. The list will be revised from time to
time by Us.

Network Specialist: A Network Provider who has limited his or her
practice to certain areas of medicine, and who is contracted with Us
to provide Covered Services to Members. A list of Network
Specialists and their locations is available to you upon enrollment
or upon request.

Non-Occupational Disease or Non-Occupational Injury: A
disease or injury that does not:

1. Arise out of (or in the course of) any work for pay or profit; or

2. Result in any way from an injury that does.

Physician: A currently licensed doctor of medicine or osteopathy.

Plan: Coverage under the Group's health benefits program as
provided under this Certificate by Oxford Health Insurance, Inc.

Precertification: An authorization given by Us that you must
receive before you can obtain certain Covered Services. We
indicate which Covered Services require Precertification in the
"Covered Services" section of this Certificate.

Preexisting Condition: A Preexisting Condition is a physical or
mental condition (regardless of the cause of the condition); for
which treatment, diagnosis or medical advice was actually
recommended or received within the prior six months ending on the
Enrollment Date.

Individuals who are enrolled under the Plan or Prior Continuous
Creditable Coverage within 30 days of birth are not subject to the
Preexisting Condition Limitation exclusion.
Children under the age of 18 who are adopted or who are placed
for adoption and who are enrolled under the Plan or Prior
Continuous Creditable Coverage within 30 days of placement or
adoption are not subject to the Preexisting Condition Limitation
exclusion.

In the absence of a diagnosis of a condition related to such
information, genetic information will not be treated as a Preexisting
Condition. Pregnancy is not a Preexisting Condition.

Premium: The total payment, including any contributions by
Subscribers, from Group to Us for coverage.

Prior Continuous Creditable Coverage:

1. Employer group health plans (including self-funded plans);
health insurance coverage (including individual policies);

2. Part A or B of Medicare; Medicaid (other than coverage
consisting solely of benefits under section 1928); the Federal
Employees Health Benefits Plan;

3. Military or veterans benefits; and

4. Indian Health Service or tribal organization programs; a health
plan offered under chapter 89 of title 5; United States Code; a
public health plan as defined in the Health Insurance Portability and
Accountability Act regulations; a health benefit plan under section
5 (e) of the Peace Corps Act; and state high risk pools are all
creditable coverage.

Creditable coverage is continuous only if the gap between the
Enrollment Date under the new coverage and the prior coverage is
not more than 63 days.

Therefore:

if the prior coverage is not creditable; or

if such a gap occurs between the Prior Continuous Creditable
Coverage and new coverage the Member does not receive
credit for their prior coverage.

Rehabilitation Facility: A currently licensed and accredited facility
which primarily provides physical therapy treatment. Such facilities
must be contracted with Us in order for Members to receive In
Network Covered Services.

Service Area: The geographical area, designated by Us and
approved by the State of New York.

Skilled Nursing Facility: An institution or a distinct part of an
institution that is: currently licensed or approved under state or local
law; primarily engaged in providing skilled nursing care and related
services as a Skilled Nursing Facility, extended care facility, or
nursing care facility approved by the Joint Commission on
Accreditation of Health Care Organizations or the Bureau of
Hospitals of the American Osteopathic Association, or as a Skilled
Nursing Facility under Medicare law; or as otherwise determined by
Us to meet the standards of any of these authorities.
Specialized Rehabilitation Facility: A Hospital or other facility
that is certified by either the New York division of Alcoholism and
Alcohol Abuse or the division of Substance Abuse Services for the
treatment of alcohol or drug dependent individuals, respectively. It
provides nursing, medical counseling and therapeutic services to
such individuals according to individualized treatment plans. Such
facilities must be contracted with Us in order for Members to
receive Covered Services. Transitional living facilities are excluded
from this definition.

Subscriber: An employee or member of the Group 1) who meets
all applicable eligibility requirements of this Certificate, 2) whose
Enrollment Form has been accepted by Us, and 3) on whose behalf
the Group has paid any applicable Premium. This term is
synonymous with certificate holders, insureds and
participants.

Totally Disabled: A Subscriber who is prevented because of injury
or disease from performing their regular or customary occupational
duties and is not engaged in any work or other gainful activity for
pay or profit. A Covered Dependent, who is prevented because of
injury or disease from engaging in substantially all of the normal
activities of a person of like age and sex who is in good health.

Urgent Care: Urgent Care is medical care for a condition that
needs immediate attention to minimize severity and prevent
complications, but is not a Medical Emergency. Urgent Care may
be rendered in a Physician's office or Urgent Care Center.

Urgent Care Center: A licensed facility (except Hospitals) which
provides Urgent Care.

Us, We, Our: Oxford Health Insurance, Inc. and anyone to whom
we legally delegate to perform, on Our behalf, under the
Agreement.

Usual, Customary and Reasonable (UCR) Charge: The UCR
schedule is a compilation of the maximum allowable fees for
covered medical services, supplies and drugs. The maximum
allowable fee on the UCR schedule will be the lesser of (1) the
amount charged, (2) the amount the provider agrees to accept as
reimbursement for the particular covered services, supplies and/or
drugs, or (3) the amount that in Our discretion is the usual,
customary and reasonable fee for particular covered services,
supplies and/or drugs. When We determine the usual, customary
and reasonable fee, Oxford will consider data compiled by and
guidelines from Ingenix, Medicare and other sources recognized by
the health insurance industry and federal government payers of
health care claims as a basis for evaluating and establishing fees
for covered services, supplies and drugs. Normally, the data
utilized to compile the UCR fee schedule will be based upon the
geographic location where the services are provided or a
comparable locale. There will be instances where national data will
be utilized when the data source does not compile data
geographically. The data We choose to consider when establishing
a UCR fee schedule will be based upon the level of reimbursement
purchased by an employer for the benefit of the employers group
plan. We will implement policies and procedures to further describe
the methodology We apply to establish the UCR Fee Schedule.
OXFORD HEALTH INSURANCE, Inc.

OHINY R LS BU 905 1 OHINY Benefit Group Update Rider 5.06
Benefit Update 2006 Rider

I. WHAT HAPPENS IF I LOSE COVERAGE?

Section 1, Termination or Loss of Eligibility: Coverage Options,
Subsection I, COBRA, Item A has been replaced with the
following:

Dependents.

If you and your Covered Dependents become ineligible under the
Certificate due to (a) termination of your employment for any reason,
or (b) a reduction in your hours of employment, coverage may be
continued under this Certificate for you and/or your Covered
Dependents, subject to the following:

1. You and/or your Covered Dependents must elect to continue
such coverage and coverage by the Plan within the 60-day
period described in the Notice of Federal Continuation Rights
given by the Group to you and/or your Covered Dependents;
2. You and/or your Covered Dependents make the required
contributions;
3. You and/or your Covered Dependents comply with all other
terms and conditions under this Certificate.

II. GENERAL ADMINISTRATIVE POLICIES AND
PROCEDURES

Subsection 6, Medicare and Other Government Programs, has
been replaced with the following:

6. Medicare and Other Government Programs

This Plan is not intended to duplicate any coverage for which
Members are, or could be eligible for, such as Medicare. We
will coordinate benefits with Medicare in accordance with
applicable law. You agree to complete and submit to Us any
documentation reasonably necessary for Us to receive or
assure reimbursement under Medicare.

Benefits for Medicare Eligibles Who are Covered Under
this Certificate

1. If your Group has 20 or more employees, any active employee
or spouse of an employee who becomes or remains a member
of the Group Covered by this Certificate, after becoming
eligible for Medicare due to reaching age 65, will receive the
benefits of this Certificate as primary unless such Subscriber
elects Medicare as his or her primary coverage. However, the
Subscriber must notify Us of the election by signing and
submitting to Us an election card which indicates his or her
choice. He or she must also pay any required premium. Any
Subscriber who elects Medicare as primary shall not be

eligible for coverage under this Certificate as of the date of
election.

2. If your Group has 100 or more employees or your group is an
organization which includes an employer with 100 or more
employees, any active employee, spouse of an active
employee or Dependent child of an active employee who
becomes or remains a member of the Group Covered under
this Certificate, after becoming eligible for Medicare due to
disability, will receive the benefits of this Certificate as primary
unless the Subscriber elects Medicare as his or her primary
coverage. However, the Subscriber must notify Us of his or
her election by signing an election card which indicates his or
her choice. He or she must also pay any required premium.

3. Any Subscribers who are not subject to subsections 1 and 2 of
this Section and who are Medicare eligible will receive the
benefits of this Certificate reduced by any benefits available
under Medicare Parts A and B. This applies even if the
Subscriber fails to enroll in Medicare or does not claim the
benefits available under Medicare.

Medicare Part D

If Medicare Part D has been purchased, we will coordinate benefits
with Part D regardless of whether you are subject to subsection 1, 2
or 3.

II. DEFINITIONS

The definition of Enrollment Date in Section XV, Definitions is
deleted and replaced with the following:

Enrollment Date: The Enrollment Date is the first day on
which you are able to receive benefits under a group health
plan, or if the plan imposes a waiting period, the first day of
your waiting period.

The definition of Prior Continuous Creditable Coverage in
Section XV, Definitions has been replaced with the following:

Prior Continuous Creditable Coverage:

1. Employer group health plans (including self-funded plans);
health coverage (including individual policies);

2. Insured and non-insured public health plans including
plans established or maintained by a state or the federal
government (including S-Chip plans, state high risk pools,
Medicare Part A and Part B and Medicaid); and health plans
established and maintained by a foreign country or political
subdivision;

OXFORD HEALTH INSURANCE, Inc.

OHINY R LS BU 905 2 OHINY Benefit Group Update Rider 5.06

3. Military or veterans benefits;

are all creditable coverage.

Creditable coverage is continuous only if the gap between
the new coverage and the prior coverage is less than 63
days. Therefore, if there is a gap of 63 or more days
between the prior creditable coverage and new coverage,
the prior creditable coverage is not continuous. The
Member does not receive credit for their prior creditable
coverage.

III. MISCELLANEOUS PROVISIONS

This Rider forms a part of the Agreement between Oxford Health
Insurance, Inc. ("Us") and the Group. Unless otherwise agreed to in
writing between Us and the Group, this Rider becomes effective on
the date the Agreement becomes effective.

This Rider supersedes any amendment or rider providing coverage
described above previously issued by Us. In the event of a conflict
between the provisions of this Rider and the Certificate, the
provisions of this Rider will prevail. All other terms and conditions of
the Certificate remain in full force and effect.

OXFORD HEALTH PLANS
OHI NY UCR-150 10/03 1 OHI NY UCR Standard 1/04
UCR Rider UCR Rider UCR Rider UCR Rider
The following Rider has been purchased by your employer group to
supplement the coverage outlined in your Certificate of Coverage.
I. Definitions The definition of Usual, Customary and
Reasonable (UCR) Charge in your Certificate is revised as follows:
Usual, Customary and Reasonable (UCR) Charge: The UCR
schedule is a compilation of the maximum allowable fees for
covered medical services, supplies and drugs. The maximum
allowable fee on the UCR schedule will be the lesser of (1) the
amount charged, (2) the amount the provider agrees to accept as
reimbursement for the particular covered services, supplies and/or
drugs, or (3) the amount that in Our discretion is the usual,
customary and reasonable fee for particular covered services,
supplies and/or drugs. When We determine the usual, customary
and reasonable fee, Oxford will consider data compiled by, and
guidelines from, Ingenix, Medicare and other sources recognized
by the health insurance industry and federal government payers of
health care claims as a basis for evaluating and establishing fees
for covered services, supplies and drugs. Normally, the data
utilized to compile the UCR fee schedule will be based upon the
geographic location where the services are provided or a
comparable locale. There will be instances where national data will
be utilized when the data source does not compile data
geographically. The data We choose to consider when
establishing a UCR fee schedule will be based upon the level of
reimbursement purchased by an employer for the benefit of the
employers group plan.
II. Miscellaneous Provisions
Insurance, Inc. (Us) and the Group. Unless otherwise agreed to
in writing between the Group, and Us this Rider becomes effective
on the date the Agreement becomes effective.
This Rider supersedes any amendment or rider concerning the
above-mentioned provisions previously issued by Us. In the event
of a conflict between the provisions of this Rider and the Certificate,
the provisions of this Rider will prevail. All other terms and
conditions of the Certificate remain in full force and effect.
OXFORD HEALTH PLANS
OHINY R LS REIM PTE 905 1 NY OHI PTE EPO Rider 10/05
Reimbursement Reimbursement Reimbursement Reimbursement Rider Rider Rider Rider
I. Certificate Revision
Your Certificate of Coverage has been revised. Subsection 2,
Payment Options, of Section IX, What Happens if a Provider Bills
Me? has been deleted and replaced with the following:
II. Reimbursement
When you receive Covered Services from a Non-Network Provider,
We will reimburse you directly, and you will then be responsible for
reimbursing the Non-Network Provider. You may not assign your
right to reimbursement under this Certificate to a Non-Network
Provider without Our consent. However, in Our discretion, We may
pay a Non-Network Provider directly. Our decision to not accept
assignment is final.
When Non-Network Providers are accessed during an In-
Network procedure: During an In-Network, inpatient admission or
other facility-based or office procedure, you may receive Covered
Services from a Non-Network Provider (e.g., anesthesiologist,
second surgical assistant). We understand that this is not under
your control and can happen without your knowledge. In such
instances, We will pay the lesser of the Non-Network Providers
billed charges or a charge We Negotiate with the provider. There
will be no additional costs to you. However, because such
providers are not contracted with Us, We will not directly reimburse
them. As with all Non-Network Providers, We will send a check for
the billed amount to you (the Subscriber). We will also send you the
provider's name and address so that you may reimburse the
provider for their services.
III. Miscellaneous Provisions
Insurance, Inc. ("Us") and the Group.
This Rider supersedes any amendment or rider concerning the
above-mentioned provisions previously issued by Us. In the event
of a conflict between the provisions of this Rider and the Certificate,
the provisions of this Rider will prevail. All other terms and
conditions of the Certificate remain in full force and effect.
OXFORD HEALTH PLANS

OHINY R LS BU ELIG 1206 NY OHI Eligibility Update Rider 1.07

Eligibility Update Rider

Section III. Who Can Join?

Section III, Who Can Join, Subsection 1, Eligibility,
Part B, Dependents, Items 1 and 2 have been
replaced with the following:

1. The Subscriber's lawful spouse who resides with the
Subscriber or has reasonable access to the Service
Area; or

2. Any unmarried child who is either a step-child, legally
adopted child or proposed adoptive child who is dependent
upon the Subscriber during any waiting period prior to the
finalization of adoption, or a natural child of either the
Subscriber or the Subscriber's spouse. In addition, a child for
whom Subscriber or Subscriber's spouse is a court appointed
legal guardian is eligible for coverage as a Covered
Dependent provided proof of such guardianship is submitted
with the Dependent's Enrollment Form. The child must also
be dependent upon the Subscriber for support as defined by
the United States Internal Revenue Code and federal
regulations.

Please Note: If a "child" as described above does not live with the
Subscriber or have access to the Service Area, coverage is available
as follows: If the Plan does not provide Out-of-Network coverage,
coverage will be limited to Medical Emergencies. If The Plan does
provide Out-of-Network coverage, all Covered Services will be
reimbursed on an Out-of-Network basis except for Medical
Emergencies (which will be paid on an In-Network basis). In both
instances, In-Network coverage is available only in the Service Area.

Section III, Who Can Join, Subsection 2, Applying for Coverage,
Items C and D have been replaced with the following:

C. Newly Eligible Dependents. Any person who becomes a
Dependent may be enrolled by submitting an Enrollment
Form within 31 days of becoming a Dependent. Dependents
who are being enrolled pursuant to a court order must enroll
within 60 days of the date of the court order. No evidence of
good health will be required. This provision also applies to
adopted and prospective adopted children (except for
newborns as discussed below). In order for such child to be
enrolled, the Subscriber must be legally obligated for such
child's financial support .

D. Newborns and Newly Born Adopted Children. A newborn
child of the Subscriber or Subscriber's spouse will be Covered
for the first 31 days after the birth of the child if the Subscriber

completes and submits an Addition Form specifically adding
the newborn child as well as submits any applicable
Premium to the Group within 31 days following the birth. This
provision also applies to newly born adopted children if the
Subscriber files a petition pursuant to section 115-c of the
domestic relations law within 30 days of birth, and provided
no notice of revocation has been filed and consent for the
adoption has not been revoked.

IMPORTANT: Even if the Subscriber is already paying the
maximum Premium (Family Rate), an Addition Form is still
necessary. We must have knowledge of the childs presence
on the Plan in order to produce an accurate HIPAA Certificate
of Prior Coverage. You will need (and are entitled to) such
certificate if your coverage ends under this Plan.

II. MISCELLANEOUS PROVISIONS

Plans Insurance, Inc. ("Us") and the Group. Unless otherwise agreed
to in writing between Us and the Group, this Rider becomes effective

provisions of this Rider will prevail. All other terms and conditions of

OXFORD HEALTH PLANS
_________________________________________________________________________________________
OHINY R BU FMLA LS 708 NY OHI FMLA Rider 8.08


Benef i t Updat e Ri der

Your Certificate of Coverage is modified as follows:

Section VII. What Happens If I Lose Coverage?,
Subsection 5. Other Available Coverage, Item B.
Family and Medical Leave Act is deleted and

Federal law provides that certain employees can take up to
12 weeks of unpaid leave in a 12-month period for:
the birth or adoption of a child,
a serious health condition affecting the
employee or a family member,
for any qualifying exigency arising out of the fact
that the employees spouse, child or parent is on
or has been called to active duty in the Armed
Forces, or
up to 26 weeks of unpaid leave in a 12-month
period to care for an injured servicemember.

Employers subject to this law are required to keep an
employee's medical coverage in force to the same extent as
if no leave had been taken. Your obligations, including any
Premium contributions and compliance with Plan
provisions, do not change during a leave.

If your employer is subject to this law, and you are eligible for leave
under the Act, We will continue your coverage during a qualified
leave. Coverage will terminate for failure to comply with Plan
provisions, including the failure to pay Premium. You should check
with your employer regarding family or medical leaves.


Insurance, Inc. ("Us") and the Group. Unless otherwise agreed to
in writing between Us and the Group, this Rider becomes effective

provisions of this Rider will prevail. All other terms and conditions
of the Certificate remain in full force and effect.

OXFORD HEALTH PLANS
______

OHINY R BU Spouse LS 109 NY OHI Spouse Def BUR 3.09
Benef i t Updat e Ri der

Your Certificate of Coverage is modified as follows:

Section XIII. Definitions has been updated to
include the following definition of Spouse:

Spouse: A person's partner (husband or wife) in a legal marriage.
For purposes of Dependent eligibility under this Certificate, spouse
includes same sex partners who are married in jurisdictions that
recognize same sex marriages.




OXFORD HEALTH PLANS

OHINY R BU 2009 S 709 NY Small OHI 2009 BUR 11.09
[1]
2009 Amendment
Ox f or d Heal t h I nsur anc e,
I nc .
As described in this Amendment, the Certificate of Coverage is
modified as stated below.
A. The following Student Medical Leave
description has been added to Section IV,
Who Can Join, Subsection 1, Eligibility,
Paragraph B, Dependents, Item 2:
Extended Coverage for Full-time Students
Coverage for a Covered Dependent child who is a Full-time
Student and who needs a Medically Necessary leave of
absence will be extended until the earlier of the following:
One year after the Medically Necessary leave of
absence begins.
The date coverage would otherwise terminate
under the Certificate.
Coverage will be extended only when the Dependent is
covered under the Policy because of Full-time Student
status immediately before the Medically Necessary leave of
absence begins and when the Dependent's change in Full-
time Student status meets all of the following requirements:
The Dependent is suffering from a Sickness or
Injury.
The leave of absence is Medically Necessary, as
determined by the Dependent's treating Physician.
The Medically Necessary leave of absence causes
the Dependent to lose Full-time Student status for
purposes of coverage under the Certificate.
A written certification by the treating Physician is required.
The certification must state that the Dependent child is
suffering from a Sickness or Injury and that the leave of
absence is Medically Necessary.
For purposes of this extended coverage provision, the term
"leave of absence" includes any change in enrollment that
causes the loss of Full-time Student status.
B. The following Special Enrollment description
replaces the Special Enrollment description
in Section IV, Who Can Join, Subsection 2,
Applying for Coverage:
F. Special Enrollment Periods
Individuals who do not meet any of the below special
enrollment period requirements may only be enrolled at the
next Group Open Enrollment Period.

In addition, no person is eligible to re-enroll if he or she has
had coverage from Us terminated for cause as described in
the termination provisions of this Certificate.
1. Change in Family Circumstances. Subscribers who
previously declined coverage under any of the
Group's plans may join "off-cycle" when they gain a
dependent either through marriage, birth or
adoption. The Subscriber and the new
dependent(s) must enroll within 30 days of the
event (the marriage, birth or adoption). Existing
eligible dependents that had previously declined
coverage may also enroll at this time.
2. Loss of Other Coverage. If all of the following
conditions are met, an individual may be enrolled
before the next open enrollment:
the employee or dependent was covered
under another group health plan or other
health insurance at the time that coverage
under this Certificate was initially available;
and
the employee stated in writing that being
covered under other coverage was the
reason for rejecting coverage under this
Certificate; and
the previous coverage has ended because
of any of the following:
it was COBRA coverage that has
been exhausted;
the individual lost coverage due to
a loss of eligibility (legal separation,
divorce, death, termination of
employment or reduction in work
hours);
the individual lost coverage due to
a loss of eligibility under Medicaid
or Children's Health Insurance
Program (CHIP);
the employer contribution toward
such coverage was terminated.
If all of these conditions are met and he or she
otherwise meet the eligibility requirements of this
Certificate, the employee or dependent may
request enrollment. The individual must enroll
within 30 days of the termination of the previous
coverage or employer contribution. When loss of
OXFORD HEALTH PLANS

[2]
coverage is due to a loss of eligibility under
Medicaid or CHIP, coverage will begin only if we
receive the completed enrollment form and any
required premium within 60 days of the date
coverage ended.
3. Medicaid or CHIP Subsidy Eligibility. Subscribers
who previously declined coverage under any of the
Group's plans may join "off-cycle" when the
Subscriber and/or Dependent becomes eligible for
a premium assistance subsidy under Medicaid or
CHIP. Coverage will begin only if we receive the
completed enrollment form and any required
premium within 60 days of the date of
determination of subsidy eligibility.
C. The following Covered Service description
for Hearing Aids is added to Section V,
Covered Services:
Q. Hearing Aids
Hearing aids required for the correction of a hearing
impairment (a reduction in the ability to perceive sound
which may range from slight to complete deafness).
Hearing aids are electronic amplifying devices designed to
bring sound more effectively into the ear. A hearing aid
consists of a microphone, amplifier and receiver.
Covered Services are available for a hearing aid that is
purchased as a result of a written recommendation by a
Physician. Covered Services are provided for the hearing
aid and for charges for associated fitting and testing.
Covered Services under this section do not include bone
anchored hearing aids. Bone anchored hearing aids are a
Covered only for Members who have either of the following:
Craniofacial anomalies whose abnormal or absent
ear canals preclude the use of a wearable hearing
aid.
Hearing loss of sufficient severity that it would not
be adequately remedied by a wearable hearing aid.
D. The Covered Service description for External
Prosthetic Devices in Section V, Covered
Services is revised as follows:
I. External Prosthetic Devices
We Cover prosthetic devices (including wigs) that are worn
externally and that temporarily or permanently replace all or
part of an external body part that has been lost or damaged
because of an injury or disease. Wigs are Covered only
when a Member has severe hair loss due to injury or
disease or as a side effect of the treatment of a disease
(e.g., chemotherapy). We do not Cover wigs made from
human hair unless the Member is allergic to all synthetic
wig materials.
For adults, We Cover the cost of only one prosthetic
device, per limb, per lifetime. For children, the cost of
replacements is also Covered but only if the previous
device has been outgrown. Coverage is for standard
equipment only. We do not otherwise Cover the cost of
repairs or replacement.
In accordance with Our Medical Policy, external breast
prostheses following a mastectomy are also Covered.
E. The Covered Service description for
Reconstructive and Corrective Surgery in
Section IV, Covered Services is revised as
follows:
E. Reconstructive and Corrective Surgery
Reconstructive and corrective surgery is Covered only
when:
1. it is performed to correct a congenital birth defect of
a Covered Dependent child which has resulted in a
functional defect; or
2. it is incidental to surgery or follows surgery that was
necessitated by trauma, infection or disease of the
involved part; or
3. it is breast reconstruction on one or both breasts
(including surgery on the healthy breast to restore
and achieve symmetry). Implanted breast
prostheses following a mastectomy are also
Covered.
Important: Reconstructive and corrective surgery is not a
Covered Service unless it meets the criteria stated in either
1, 2, or 3 above.

F. The following Exclusion description for
Hearing Aids replaces the Exclusion
description in Section VI, Exclusions and
Limitations, Item 14:
14. In addition to the exclusions identified in your
Certificate of Coverage, the following are excluded
from coverage under this rider:
1. Bone anchored hearing aids except when
either of the following applies:
For Members with craniofacial
anomalies whose abnormal or
absent ear canals preclude the use
of a wearable hearing aid.
For Members with hearing loss of
sufficient severity that it would not
be adequately remedied by a
wearable hearing aid.
2. More than one bone anchored hearing aid
per Member who meets the above
OXFORD HEALTH PLANS

[3]
coverage criteria during the entire period of
time the Member is enrolled under the
Certificate.
3. Repairs and/or replacement for a bone
anchored hearing aid for Members who
meet the above coverage criteria, other
than for malfunctions.
G. The State of New York Continuation
provision in Section IX, What Happens If I
Lose Coverage, Subsection II State of New
York Continuation, Paragraph A Continuation
of Coverage for You and Your Covered
Dependents has been revised as follows:
A. Continuation of Coverage for You and Your
Covered Dependents
If a Member's coverage under this Certificate would end
because the Subscriber:
has terminated employment ; or
has become a member of a class of employees
who are not eligible for coverage
the Member and/or Covered Dependents may apply for
State Continuation. Members who wish to elect State
Continuation must request the coverage, in writing, within
the 60-day period following the later of: the date of the
termination or ineligibility; or the date the Member is given
notice by the Group.
Additionally, if the Member elected continuation coverage
under federal law (for any reaon other than disability), the
Member may also elect to continue coverage under state
law for up to an additional 18 months. If continuation
coverage under federal law was elected due to disability as
defined by Title II or Title XVI of the Social Security Act, the
Member may elect to receive up to seven months of
continuation coverage under state law.
The coverage under this subsection A. will end on the
earliest of:
1. 36 months after the date the Member became
ineligible under the Certificate if continuation
coverage under federal law was not elected;
2. 18 months from the date continuation began if such
continuation was elected after termination of
continuation coverage under federal law (seven
months if continuation under federal law was
elected due to disability).
4. The date any Member becomes covered or eligible
for coverage under Medicare;
5. The date any Member becomes covered or eligible
for coverage under another group health plan (as
either a subscriber or dependent) unless that plan
restricts coverage of a pre-existing condition of the
Member; or
6. The date that coverage under this Certificate is
discontinued with respect to all employees of the
Group.
H. Copayments, Deductibles and Coinsurance
With respect to the Covered Services described in this
amendment, all Covered Services are subject to the
Copayment or Coinsurance listed in your Summary of
Benefits. All Covered Services are also subject to any
applicable Plan Deductibles, benefit limits and UCR
Reimbursement as identified on your Summary of Benefits.
I. Miscellaneous Provisions
This Amendment forms a part of the Agreement between
Oxford Health Insurance, Inc. ("Us") and the Group. Unless
otherwise agreed to in writing between Us and the Group,
this Amendment becomes effective on the date the
Agreement becomes effective.
This Amendment supersedes any amendment or rider
providing coverage described above previously issued by
Us. In the event of a conflict between the provisions of this
Amendment and the Certificate, the provisions of this
Amendment will prevail. All other terms and conditions of

OXFORD HEALTH PLANS
____

OHINY R YoungAdult LS 1109 NY OHI Young Adult Dep 29 Age Rider 4.10

New Yor k Young Adul t
Cover age f or Dependent s
Thr ough Age 29

This Rider provides notice of a Young Adults ability to purchase
coverage under this plan.

A. The following Dependent eligibility information
has been added to Section I, Who Can Join,
Subsection 1, Eligibility, Paragraph B,
Dependents:

3. New York Young Adult Coverage for Dependents Through
Age 29

If a Dependent child is not eligible to enroll on a group health
plan because they exceed the limiting age for Dependents
under that plan as identified in the Summary of Benefits, the
child, or their parent, may elect to purchase such benefits as a
Young Adult until his or her 30
th
birthday, subject to the
following provisions:

a. Conditions for Election A Dependent child is eligible to
elect coverage as a Young Adult if all of the following
conditions are met:

i. the Young Adult is the child of an employee or other
group member insured under the Group Agreement;
and
ii. the Young Adult is under 30 years of age; and
iii. the Young Adult is not married; and
iv. the Young Adult is not insured or eligible for
insurance (as an employee or member) under a self-
funded or fully-insured employer sponsored plan;
and
v. the Young Adult lives, works or resides in New York;
and
vi. the Young Adult is not covered under Medicare.

The Dependent does not have to be a student, live with
the Subscriber or be financially dependent upon the
Subscriber in order to purchase the coverage.

b. Election of Young Adult Coverage To elect this
coverage, the Young Adult or their parent must make
written election to Us and pay any required premium. The
effective date of the Young Adults coverage will be the
later of the following:

i. the date the Young Adult gives written notice to us;
or
ii. the date the Young Adult pays the first premium; or
iii. the date the Young Adult would otherwise lose
coverage due to attainment of the limiting age.

A Young Adult (or their parent) has the following
opportunities to elect this coverage:
i. For a Dependent whose coverage has not yet
terminated due to the attainment of the limiting age
as identified in the Summary of Benefits the written
election must be made within 60 days of termination
of coverage due to attainment of the limiting age.
ii. Coverage may be elected within 60 days of newly
meeting the eligibility requirements for the Young
Adult option (e.g., loss of employer sponsored
coverage, divorce, etc.).
iii. Coverage may be elected during the annual 30-day
open enrollment period. If a Young Adult elects
coverage during the open enrollment period, they
are entitled to prospective coverage no later than 30
days after written notice of the election is received
and premium is paid.
iv. Coverage may be elected during the initial 12 month
open enrollment period following the effective date
of the law (September 1, 2009) if the Young Adults
coverage terminated under the terms of the parents
Group Agreement prior to September 1, 2009.

c. Young Adult Benefits The Young Adults benefits will be
identical to the coverage provided to the Young Adults
parent who is covered as an Employee under the Group
Agreement. If coverage is modified for Dependents who
are under the limiting age as identified in the Summary of
Benefits, the coverage for Young Adults provided by this
Rider will be modified in the same manner. Evidence of
insurability is not required for this continued coverage.

The children of the Young Adult are not eligible for
coverage under the Young Adult option.

d. Application of a Pre-Existing Conditions Exclusion If the
coverage provided to the Young Adults parent includes a
Pre-Existing Conditions Exclusion, coverage for the
Young Adult will be subject to the Pre-Existing Conditions
Exclusion as outlined in the Certificate of Coverage.

e. Continuation The Young Adult option does not affect
any continuation rights under COBRA or New York State
Continuation coverage. Further, a Young Adults eligibility
for health insurance through a former employer under
COBRA or New York State Continuation does not
preclude the Young Adult from electing the Young Adult
option.

e. Termination of Coverage Coverage for a Young Adult
under this provision will end of the first of the following:

i. the date the Young Adult voluntarily terminates
coverage pursuant to the terms of the Group
Agreement or
OXFORD HEALTH PLANS
____

OHINY R YoungAdult LS 1109 NY OHI Young Adult Dep 29 Age Rider 4.10
ii. the date the Young Adult no longer meets any of the
above referenced conditions for election; or
iii. the end of the period for which premium has not
been paid within the grace period; or
iv. the date that the Group Agreement is terminated
and not replaced with another group policy; or
v. the date the Group Agreement ceases to provide
coverage to the Young Adults parent who is the
Employee under the Group Agreement.

The Young Adult does not have a separate COBRA or
New York State Continuation right once coverage under
the Young Adult option ends.

B. MISCELLANEOUS PROVISIONS



OXFORD HEALTH PLANS
______________
OHINY R BU CONG ANOM 110 NY OHI Congenital Anomaly Amendment 10.10
2010 Congeni t al Anomal y
Amendment
A. The following Covered Service description for
Oral Surgery i s added to Section IV, Covered
Services:
F. Oral Surgery
General dental services are not Covered. The following
limited dental and oral surgical procedures are Covered in
either an inpatient or outpatient setting:
1. Oral surgical procedures for jaw bones or surrounding
tissue and dental services for the repair or replacement
of sound natural teeth that are required due to
accidental injury. Replacement is Covered only when
repair is not possible (please see the Exclusions and
Limitations section of this Certificate). Dental services
must be obtained within 12 months of the injury.
2. Oral surgical procedures for jaw bones or surrounding
tissue and dental services necessary due to congenital
disease or anomaly.
3. Oral surgical procedures required for the correction of
a non-dental physiological condition which has resulted
in a severe functional impairment.
4. Removal of tumors and cysts requiring pathological
examination of the jaws, cheeks, lips, tongue, roof and
floor of the mouth. Cysts related to teeth are not
Covered.
5. Surgical/nonsurgical medical procedures for TMJ and
orthognathic surgery may be Covered if Precertified
and approved by Our Medical Director.
Oral Surgery, including the dental services described
above, requires Precertification. When possible, please
obtain the Precertification at least 14 days in advance
of the surgery or procedure.
B. The following Exclusion description for Dental
Services replaces the Exclusion description in
Section V, Exclusions and Limitations, Item 13:
1. Services in Connection with Elective Cosmetic
Surgery. We do not Cover cosmetic surgery, except that
cosmetic surgery shall not include reconstructive surgery
when such service is incidental to or follows surgery resulting
from trauma, infection or diseases of the involved part, and
reconstructive surgery because of congenital disease or
anomaly of a Covered Dependent child which has resulted in
a functional defect.
2. Dental Services. We do not Cover dental services
related to the care, filling, removal or replacement of teeth.
We do not Cover the treatment of injuries or diseases of the
teeth, or gums including, but not limited to: apicoectomy,
orthodontics, root canals, soft tissue impaction, alveolectomy,
and the treatment of periodontal disease. As described in
Oral Surgery, only dental services required to treat
accidental injury of sound, natural teeth and services required
to treat congenital disease and anomaly are Covered.
Replacement of Sound Natural Teeth. Replacement of
sound natural teeth is Covered only when Medically
Necessary to treat an accidental injury, a congenital disease
or a congenital anomaly. Further, it is Covered only when
repair is not possible. Please note, all denials for the services
described above are based on Medical Necessity. If
coverage is denied, you are entitled to a Utilization Review
Appeal.
OXFORD HEALTH PLANS

OHINY R AMD 2011 LS 111 NY OHI 2011 Amendment 4.11
[1]
2011 Amendment

A. The following Covered Service description
for Out-of-Network Dialysis is added to
Section IV, Covered Services:
Out-of-Network Dialysis
Coverage may be provided for dialysis treatment received
from an Out-of-Network provider on an In-Network basis if
the Member is traveling temporarily out of the Service Area
if all of the following conditions are met:
the Out-of-Network provider is licensed to practice
and is authorized to provide dialysis; and
the Out-of-Network Provider is located outside of
Our Service Area; and
the In-Network provider treating the Member for the
condition must write an order for dialysis, noting
that in his/her opinion the dialysis is necessary; and
the Member has notified Us, in writing, at least 30
days in advance of the proposed date(s) of the Out-
of-Network dialysis treatment; and
We pre-approve the dialysis treatment and
schedule; and
treatment is limited to no more than 10 Out-of-
Network treatments in a Calendar Year.
Please note: With respect to the 30 day advance notice
requirement, if the Member must suddenly travel out of the
service area (for example, due to family or other
emergency) shorter notice may be allowed, provided that
We have enough time to review the travel and treatment
plans.
Coverage will be provided subject to the same limitations,
exclusions and terms as other similar benefits, including
utilization review, annual deductibles, copayments and
coinsurance. If the Out-of-Network provider charges more
than Our contracted rate for In-Network services, the
Member is responsible for paying the difference between
the billed charges and the In-Network contracted rate.
Please see your Certificate of Coverage and Summary of
Benefits for details about your plan.

B. The following description for the claims
submission timeline is added to Section IX,
What Happens if a Provider Bills Me?,
Subsection 3. Limitations:
3. Limitations.
All requests for reimbursement must be made within 120
days of the date Covered Services were rendered. Failure
to request reimbursement within the required time will not
invalidate or reduce any claim if it was not reasonably
possible to provide such proof within the 120-day period.
However, such request must be made as soon as
reasonably possible thereafter.
All reimbursements to non-Network Providers are subject
to UCR unless you were referred to a non-Network
Provider by your PCP or Us.
C. Miscellaneous Provisions
This Amendment forms a part of the Agreement between
Oxford Health Insurance, Inc. ("Us") and the Group. Unless
otherwise agreed to in writing between Us and the Group,
this Amendment becomes effective on the date the
Agreement becomes effective.
This Amendment supersedes any amendment or rider
providing coverage described above previously issued by
Us. In the event of a conflict between the provisions of this
Amendment and the Certificate, the provisions of this
Amendment will prevail. All other terms and conditions of
OXFORD HEALTH PLANS

OHINY EXT APPLS LS 0112 NY OHI External Appeals Amendment 3.12


External Appeal
Amendment

As described in this Amendment, the Member Handbook is

A. The provision in the section Initial
Coverage Determination Timeframes in
subsection Initial Utilization (Medical
Necessity) Determinations is replaced
with the following:

Initial Utilization (Medical Necessity)
Determinations

What are utilization review issues?

Utilization Review issues include items that concern
Medical Necessity Determinations and decisions
involving treatment or services that are considered
experimental or investigational, when the treatment
or services meet the criteria set forth by New York
State. Although many determinations are made prior
to services being rendered, Medical Necessity
Determinations may be made after services are
rendered. All services are subject to a review by
Us to determine the Medical Necessity of proposed
services, services currently being provided, or
services already provided. Denials will be made by
the appropriate clinical personnel.

B. The provision in the section Appeals,
Grievances and Complaints in
subsection External UR Appeal is

External UR Appeals

You, your Designee and, in connection with
Retrospective Adverse Determinations, your
Provider, have the right to request an External UR
Appeal in the following situations:

1. We have denied coverage on the basis that the
service does not meet Our requirements for
medical necessity, appropriateness, health care
setting, level of care or effectiveness of a
covered benefit. In this instance:

The service, procedure or treatment
must otherwise be a covered service
under your contract; and
You must have received a final
adverse determination (FAD) through
Our first level of internal appeal
process and We must have upheld the
denial or both We and you have
agreed to waive any internal appeal or
you apply for an expedited external
appeal at the same time as you apply
for an expedited internal appeal.
2. We have denied coverage on the basis that the
service is an experimental or investigational
treatment. You must satisfy the following two
(2) criteria:

The service must otherwise be a
covered service under your contract;
and
You must have received a final
adverse determination (FAD) through
Our first level of internal appeal
process and We must have upheld the
denial or both We and you have
agreed to waive any internal appeal or
you apply for an expedited external
appeal at the same time as you apply
for an expedited internal appeal.

Your attending physician must certify that your
condition or disease is one for which standard
health services are ineffective or medically
inappropriate or one for which there does not
exist a more beneficial standard service or
procedure covered under your contract or one
for which there exists a clinical trial or rare
disease treatment (as defined by law).

Your attending physician must have
recommended one of the following:

A service, procedure or treatment that
two (2) documents from available
medical and scientific evidence
indicate is likely to be more beneficial
to you than any standard covered
service (only certain documents will be
OXFORD HEALTH PLANS

Please Note: The 4 month timeframe
for requesting an External Appeal
begins upon receipt of the FAD
regardless of whether you decide to
initiate an internal Second-Level Appeal
as described in this section. If you
decide to initiate a Second-Level UR
Appeal, you do not waive the option to
file an External Appeal with the New
York State DOI. However, you may
miss the 4 month timeframe for
requesting an External Appeal.
considered in support of this
recommendation your attending
physician should contact the State in
order to obtain current information as
to what documents will be considered
or acceptable); or

A clinical trial for which you are eligible
(only certain clinical trials can be
considered);or

A rare disease treatment for which
your attending physician certifies that
there is no standard treatment that is
likely to be more clinically beneficial to
you than the requested service, the
requested service is likely to benefit
you in the treatment of your rare
disease, and such benefit outweighs
the risk of the service. In addition,
your attending physician must certify
that your condition is a rare disease
that is currently or was previously
subject to a research study by the
National Institutes of Health Rare
Disease Clinical Research Network or
that it affects fewer than 200,000 U.S.
residents per year.

For purposes of this section, your attending
physician must be a licensed, board-certified or
board eligible physician qualified to practice in
the area appropriate to treat your condition or
disease. In addition, for a rare disease
treatment, the attending physician may not be
your treating physician.

Regarding Medical Necessity decisions, We may charge you
a fee of up to twenty-five dollars per External Appeal, not to
exceed $75 in a single year. In the event the External
Appeal Agent overturns the FAD, the fee will be refunded.
We will not require you to pay a fee if you are a recipient of
medical assistance or is covered by a policy pursuant to the
child health insurance plan program. Additionally, We will
not require you to pay a fee if the fee will pose a hardship to
you as determined by Us.

Regarding Experimental and Investigational decisions,
payment for an External Appeal Will be Our responsibility.
We will make payment to the External Appeal Agent within
45 days from the date We receive the Appeal determination.
We will be obligated to pay the amount together with
applicable interest in the event that payment is not made
within 45 days.

How to File an External Appeal

Non-Expedited: You have 4 months to initiate an External
Appeal after you receive notice from Us of a FAD or denial or
after both We and you agree to waive any internal Appeal.

Requests for External Appeals must be in writing on an
External Appeal application form. The application form will
include instructions on how to complete and submit the form
to the superintendent. You or your Designee (and Provider,
if applicable) must release all pertinent medical information
concerning your medical condition and request for services.
The application form is available from any of the following
New York State Department of Financial Services
at 1-800-400-8882 or www.dfs.ny.gov;
New York State Department of Health at
www.health.state.ny.us; or
Our Customer Service Department at the number
in the front of this Handbook.

Requests for External Appeals that have been determined by
the superintendent to be eligible for External Appeal will be
randomly assigned to a Certified External Appeal Agent
according to a process prescribed by the commissioner and
superintendent.

We will forward the medical and treatment plan records We
relied upon in making our determination to the External
Appeal Agent. You, and your Provider where applicable, will
have the
opportunity to
submit additional
documentation to
the External
Appeal Agent
within the 4
months period.
If the
documentation
represents a
material change
from the
documentation
upon which We
based Our
Adverse
Determination or
denial, We will
have three
business days
OXFORD HEALTH PLANS

to consider the documentation and amend or confirm Our
Adverse Determination or denial.

The External Appeal Agent will make a determination with
regard to the Appeal within thirty days of the receipt of your
request. However, the External Appeal Agent may request
additional information from you, your Provider and Us within
the thirty day period. In this case, the External Appeal
Agent will have up to five additional business days to
make a determination. In either scenario, the External Appeal
Agent will notify you and Us, in writing, of the Appeal
determination within two business days of making the
determination.

Expedited: If your Physician states that a delay in providing
the Health Care Service would pose an imminent or serious
threat to your health, the External Appeal will be completed
within three days of the request and the External Appeal
Agent will make every reasonable attempt to immediately
notify you and Us of its determination by telephone or
facsimile, followed immediately by written notification of the
determination.

Review Process

Medical Necessity: For External Appeals requested in
connection with a Health Care Service being deemed not
Medically Necessary, the External Appeal Agent will review
Our FAD and will make a determination as to whether We
acted reasonably and with sound medical judgment and in
your best interest. When the External Appeal Agent makes
its determination, it will consider: Our clinical standards; the
information provided concerning you; the attending
Physician's recommendation; applicable and generally
accepted practice guidelines developed by the federal
government; or national or professional medical societies,
boards and associations. Any such determination will:
be conducted only by one or a greater odd number
of Clinical Peer Reviewers.
be accompanied by a notice of Appeal
determination which will include the reasons for the
determination. Where the FAD is upheld on Appeal,
the notice will include the clinical rationale (if any)
for the determination.
be subject to the terms and conditions generally
applicable to benefits under your Certificate.

Experimental or Investigational: For External Appeals
requested in connection with a Health Care Service that has
been determined to be Experimental or Investigational,
the External Appeal Agent will review the proposed Health
Care Service or procedure for which coverage has been
denied and, in accordance with the External Appeal Agent's
investigational treatment review plan, make a determination
as to whether the patient costs of such Health Care Service
or procedure will be Covered by Us. Any such determination
will:
be conducted by a panel of three or a greater odd
number of Clinical Peer Reviewers.
be accompanied by a written statement that either:
o upholds our denial of coverage; or
o indicates that the patient costs of the
proposed health service or procedure must
be covered by Us either: when a majority
of the panel of reviewers determines, upon
review of the applicable Medical and
Scientific Evidence (or upon confirmation
that the recommended treatment is a
Clinical Trial), your medical record, and
any other pertinent information, that the
proposed health service or treatment
(including a pharmaceutical product) is
likely to be more beneficial than any
standard treatment or treatments for your
Condition or Disease (or, in the case of a
Clinical Trial, is likely to benefit you in the
treatment of your condition or disease); or
when a reviewing panel is evenly divided
as to a determination concerning coverage
of the health service or procedure.
be subject to the terms and conditions generally
applicable to benefits under your Certificate.

With respect to a Clinical Trial, patient costs include all costs
of Health Care Services required to provide treatment to you
according to the design of the trial. Such costs do not
include the costs of any investigational drugs or devices, the
cost of any non-health services that might be required for you
to receive the treatment, the costs of managing the research,
or costs which would not be Covered under the policy
for non-investigational treatments.

No External Appeal Agent or Clinical Peer Reviewer
conducting an External Appeal will be liable in damages to
any person for any opinions rendered by such External
Appeal Agent or Clinical Peer Reviewer upon completion of
an External Appeal unless such opinion was rendered in bad
faith or involved gross negligence.

OXFORD HEALTH PLANS

OHINY R BU HRSA LS 512 NY OHI HRSA Amendment 7.12
[1]
Heal t h Resour c es and
Ser vi c es Admi ni st r at i on
(HRSA) Amendment

Because this Amendment reflects changes in requirements of
Federal law, to the extent it may conflict with any Amendment
issued to you previously, the provisions of this Amendment will
govern.
Because this Amendment is part of a legal document (the Group
Enrollment Agreement), we want to give you information about the
document that will help you understand it. Certain capitalized words
have special meanings. We have defined these words in the
Certificate of Coverage (Certificate).
Benefits for Breast Pumps
Covered Services defined under the Health Resources and
Services Administration (HRSA) requirement include the cost of
renting one breast pump per pregnancy in conjunction with
childbirth.
If more than one breast pump can meet your needs, Benefits are
available only for the most cost effective pump. We will determine
the following:

Which pump is the most cost effective.
Whether the pump should be purchased or rented.
Duration of a rental.
Timing of an acquisition.
Precertification is required before obtaining a breast pump.
Copayments, Deductibles and Coinsurance
The Covered Services described in this amendment are provided
at 100% when received In-Network. If Out-of-Network coverage is
available, the Covered Services described in this amendment will
be subject to the Out-of-Network Copayment or Coinsurance listed
in your Summary of Benefits Preventive Care. All Out-of-Network
Covered Services are also subject to any applicable Plan
Deductibles, benefit limits and UCR Reimbursement as identified
on your Summary of Benefits.
Miscellaneous Provisions
This Amendment forms a part of the Agreement between Oxford
Health Insurance, Inc. ("Us") and the Group. Unless otherwise
agreed to in writing between Us and the Group, this Amendment
becomes effective on the date the Agreement becomes effective.
This Amendment supersedes any amendment or rider providing
coverage described above previously issued by Us. In the event of
a conflict between the provisions of this Amendment and the
Certificate, the provisions of this Amendment will prevail. All other
terms and conditions of the Certificate remain in full force and
effect.

OXFORD HEALTH PLANS
OHI NY Info 1/04 1 OHI NY Info 1/04


INFORMATION ABOUT
YOUR OXFORD
COVERAGE

PART I

REIMBURSEMENT

Overview of Provider Reimbursement
Methodologies

Generally, Oxford pays Network Providers on a fee-for-service
basis. Fee-for-service based payment schedules differ depending
on the type of provider, geographic location, or site of service, and
may include payment based on each office visit, a hospital day,
procedure or service performed, item furnished, course of
treatment, or other units of service. A unit of service, such as a
hospital day, may include more than a single procedure or item.
We may also limit the number of services or procedures that we will
pay for during any single office visit or for any single procedure; or
for multiple procedures performed at the same time. This practice
is known as bundling and is used by many third party payers,
including the Medicare program. Some providers have agreed to
accept variable fee for service payments, payment based on a
mutually agreed upon budget, so long as they receive at least a
minimum fee. Oxford may make modifications to its fee for service
compensation mechanism during the term of your coverage.

Oxford does not typically withhold a portion of a physicians
contracted fees; which might be paid later depending on the
physicians performance or financial performance of Oxford. (The
amount retained is called a Withhold.) However, Withholds are
among the sanctions that Oxford may implement with respect to
physicians who have a demonstrated practice of not following
Oxford policies, for example, by improper billing practices,
consistently referring Members to providers who are not Network
Providers or by failing to obtain required referrals or
Precertifications. Oxford may profile Network Providers billing,
referral, utilization, or other practices, and develop other financial
disincentives for providers who do not follow Oxford's policies and
procedures during the term of your coverage.

Oxford does not generally provide Bonuses or other Incentives to
Network Providers. However, Oxford has entered into Incentive
Agreements with a few intermediaries, such as provider groups
and independent practice associations (IPAs). Incentive
Agreements may be based on membership, referrals to specialists
or hospitals and other facilities, economic factors, quality factors,
member satisfaction factors, or a combination of these and other
factors. Incentive Agreements typically, but not always, require the

group to meet mutually agreed upon quality measures as a
condition of obtaining a bonus based on cost or utilization.

Financial incentives or disincentives may also be adopted to
promote electronic billing practices or other e-commerce initiatives;
or to promote compliance with Oxford utilization management
policies. In addition, physicians may be paid at higher rates for
certain surgical procedures, if they perform the surgery in their
offices, or at ambulatory surgical centers. Oxford may enter into
additional Incentive Agreements with providers during the term of
your coverage. Network Providers who contract through
intermediaries that contract may be subject to Incentives. Oxfords
contracts with intermediaries typically, but not always, limit the
nature and scope of the Incentives the group may enter into with
Network Providers.

Oxford does not pay individual Network Physicians or practitioners
on a Capitated basis. However, as described above, Oxford has
negotiated a few Capitation Agreements with IPAs. Oxford may
enter into additional Capitation Agreements during the term of your
coverage or terminate existing Capitation Agreements.

Individual practitioners who are paid from funds available under
Capitated Agreements with IPAs are generally paid on a fee-for-
service basis, but some IPAs may pay individual primary care
physicians on a Capitated basis. In addition, practitioners
contracting through IPAs may be subject to Incentive Agreements.
IPAs with which Oxford contracts may enter into Capitation
Agreements with Network Physicians. Intermediaries with which
Oxford contracts might enter into or terminate Capitation
Agreements or Incentive Agreements with Network Physicians,
facilities or practitioners during the term of your coverage. Oxford
may audit Network Providers billing patterns, licensing compliance,
or require documentation that services billed were provided. If the
provider cannot demonstrate that services have been provided, or
that the services billed are medically necessary and consistent with
the services provided, Oxford may seek to recover funds paid to
the provider, reduce future payments to the provider, or take other
action such as a fee reduction or withhold until the provider has
corrected their behavior.

A brief description of the compensation mechanisms applicable to
different providers as of January 1, 2004 is set forth below.

Network Physicians - The compensation mechanisms used for
Network Physicians are described in the Overview above. A large
majority of Our Network Physicians are reimbursed by Oxford or an

OXFORD HEALTH PLANS

intermediary on a discounted fee-for-service basis. Some
Network Physicians have contracted with IPAs or are aligned with
other Network Physicians which either: 1) accept compensation
based upon a predetermined budget for the cost of Covered
Services to Members, or 2) are subject to an Incentive Agreement
(Bonus) based on quality and utilization measurements. In addition,
some physician groups are eligible to be paid a Bonus based either
on the total cost incurred by Oxford for Covered Services rendered
to members who select or are assigned to a member of the
physician group as their primary care physician, or other utilization
measures, such as the total number of days these members (in the
aggregate) spend in the hospital or percentage of referrals to
certain specialists, hospitals or other facilities.

Limited License Practitioners - We reimburse Limited License
Practitioners (non-Physician health care professionals) on a fee-
for-service basis. Oxford has contracted with a company to
manage our physical therapy benefit and certain other therapy
benefits. Oxford has also contracted with a company to manage
our chiropractic benefit. Oxford may enter into additional
Capitation and/or Incentive Agreements with other limited license
practitioners during the term of your coverage.

Laboratory Services - We have entered into a Capitation
agreement with a national laboratory services provider to furnish
outpatient laboratory tests for Our Members. Laboratory service
providers are reimbursed on a fee-for-service basis, with total
payment for laboratory services limited by an agreed upon budget.
The company may have a financial incentive to contain the annual
aggregate cost of laboratory related services

Pharmacy - We have entered into an arrangement with a national
pharmacy management company that, in turn, contracts with
pharmacies and manufacturers to provide pharmacy products and
services to Members. The pharmacies are paid on a fee-for-
service basis for both pharmaceuticals and dispensing the
prescriptions. The pharmacy management company also provides
certain administrative services in connection with administration of
Oxfords pharmacy benefits. If Oxford terminates this contract
before expiration of its term, Oxford will pay the pharmacy benefit
management company a fee, but this fee is reduced if costs
exceed agreed upon targets. Oxford may contract with pharmacies
known as specialty pharmacies to provide and manage benefits
for certain pharmaceuticals, such as infertility drugs.

Hospital and Other Ancillary Facilities - Reimbursement to
Network Facilities is made on a fee-for-service basis. For inpatient
services, payment is generally on the basis of a per day rate, or
on a case rate for an entire stay based on the diagnosis. In
general, Oxford negotiates agreements with individual hospitals or
hospital systems. We do not have Capitation agreements with any
of Our Network Facilities. However, we have entered into an
Incentive Arrangement with an IPA for medical management of
subacute facilities. The IPA pays contracting sub-acute facilities on
a fee-for-service basis. Certain hospitals are developing their own
programs to reduce unnecessary hospital inpatient stays and
lengths of stays. Oxford may enter into Capitation and/or Incentive
Agreements with hospitals or physicians during the term of your
coverage.

Radiology Services - Oxford, through an intermediary, has
contracted with radiologists who have agreed to be paid on a fee-
for-service basis, with total fees limited based on a mutually agreed
budget for radiology services. The company may have a financial
incentive to contain the annual aggregate cost of imaging services.

Non-Participating Providers - Providers that have not entered
into contracts with Oxford (directly or indirectly through groups),
including providers in the Oxford service area and providers
outside the Oxford service area, are paid on a fee for service basis.
Oxford has entered into agreements with preferred provider
organizations under which certain non-participating providers will
provide a discount from their usual charges. Other non-
participating providers are paid based on Oxfords determination,
using various industry standards, of the Usual, Customary and
Reasonable Charge for the service or as otherwise provided in
your summary of benefits. Oxford may seek to impose bundling
rules or other limitations on bills received from non-participating
providers, but will assure that Members are not charged more than
permitted by their benefit plan. Oxford may audit non-participating
providers billing patterns, licensing compliance, or require
documentation that services billed were provided and that the
services provided were medically necessary. Any or all of these
audits may result in non-payment to the provider for these unusual
or fraudulent practices. In some circumstances, this may result in
balance billing to the member. If that occurs, please contact
Oxford.

Effect of Reimbursement Policies - We believe that the
implementation of these reimbursement methodologies has
produced the results they were designed to accomplish (i.e.,
access to high quality providers in our service area, and cost-
effective delivery of care). Through the application of Our Quality
Assurance protocols, We continuously monitor Our Providers to
ensure that Our Members have access to the high standards of
care to which they are entitled. If a particular reimbursement policy
affects a physicians referral to a particular Network Provider, Our
Members have the right to request referral to a different Network
Provider.

Definitions - In addition to the definitions in your Certificate,
Contract, or Handbook (whichever is applicable) the capitalized
words in this attachment have the following meaning:

Bonus: An incentive payment that is paid to Physicians who have
met all contractual requirements to obtain the Bonus.

Capitation, Capitated: An agreed upon amount, usually a fixed
dollar amount or a percentage of premium, that is paid to or
budgeted for the Provider or IPA regardless of the amount of
services supplied. Capitation formulas may include adjustments for
benefits, age, sex, and other negotiated factors. Usually, the
Capitation amounts are paid or allocated on a monthly basis.

Incentive Agreements: In general, "Withholds" and "Bonuses"
are known as "Incentive Agreements." Incentive Agreements may
also include higher than standard fees, or penalties for failure to
adhere to Oxford policies, such as making referrals only to Network

OXFORD HEALTH PLANS

Providers when Network Providers are capable and available to
provide necessary services to Members, or based on the provision
of services at specific sites of service. Under such agreements,
Providers are paid less (some portion of their fee is reduced or
withheld) or paid more (such as in the form of a bonus) based on
one or more factors that may include (but are not limited to):
member satisfaction, quality of care, compliance with Oxford
policies, control of costs, and their use of services.

IPA: An IPA (independent practice association) is an organization
that contracts with physicians and other health care providers.

Us, We, Our: When coverage is provided under Oxfords
insurance company, it means Oxford Health Insurance, Inc. In
addition, it can also include third parties to whom we delegate
responsibility for providing administrative services relating to
coverage, such as utilization management.

Usual, Customary and Reasonable (UCR) Charge: The amount
charged, the amount agreed upon with a non-participating provider,
or the amount We determine to be the reasonable charge, for a
particular Covered Service. UCR determinations may be based on
Medicare fees, industry data regarding charges or costs, or other
factors. The basis for determining UCR may be different for
different benefit designs.

Withhold: Percentage of a physicians fee that is held back or
reserved as an incentive to encourage appropriate and efficient
medical treatment or billing.

PART II
UTILIZATION
MANAGEMENT PROGRAM

A. PROGRAM OVERVIEW

Oxford has developed and implemented Utilization Management
programs that are intended to reduce the volume of unnecessary
services, direct members to appropriate providers and coordinate
services among providers. In general, the utilization management
protocols We use are based on industry-standard criteria
developed by health care consultants and recognized clinical
societies.

When We contract with network managers to provide utilization
management services, they may use our protocols. In some
cases, we review and adopt some or all of the protocols that they
develop as our own . Oxfords Utilization Management Programs
are developed and implemented by the Oxford Medical Affairs
department, except as described below. Oxfords Medical Affairs
Department is headed by Our Chief Medical Officer, who is a
physician, and includes physician Medical Directors, registered
nurses, and health practitioner consultants.

B. PROTOCOL DEVELOPMENT OVERVIEW

In developing our Utilization Review protocols, Oxford typically
utilizes guidelines from outside sources, which include external
consultants, including but not limited to Milliman & Robertson UM
principles. We modify these protocols based on Our experience,
medical evidence, and legislative requirements. All such policies
are periodically reviewed and updated

C. CASE MANAGEMENT

Medical Case Management - Medical Case managers work with
Providers and Members to assess, plan, coordinate, and evaluate
options, settings, services and time frames required to meet a
Members individual healthcare needs. Medical case management

is a clinical goal-directed process requiring communication and
coordination of all available resources to promote both quality and
cost-effective outcomes. The interventions typically range from
simple hospital discharge planning to complex case management
in the outpatient setting.

Disease Management and Complex Case management - Our
Disease Management Services are intended for complex or chronic
cases that are likely to result in high utilization of medical services.
These cases include but are not limited to, patients with the
following conditions required for treatment:

HIV
End Stage Renal Disease
Transplants (organ and bone marrow)
High-risk maternity and high-risk neonates (newborns)
Asthma
Diabetes
Congestive heart failure
Coronary Artery Disease
Rare chronic illnesses

During the term of your coverage, Oxford may introduce new
disease management programs, contract with other companies to
provide disease management, and terminate or modify existing
disease management programs. For more information about
disease management programs, contact Oxford.

Concurrent Review - Concurrent review is the review of care that
is in progress for purposes of determining the extent and scope of
coverage during a course of treatment. Monitoring the course of
treatment through the concurrent review process enables Us to
assist with discharge planning from hospital inpatient stays. In
addition, it assists us in identifying alternative options of care, such
as home care, and when it is appropriate, We can begin case
management. We render benefit decisions regarding continuation
of stay based on protocol criteria.

Discharge Planning - We begin planning for post-Hospitalization
care when We are informed of a planned admission. This is one
reason that it is essential that your Provider notify Us of your

OXFORD HEALTH PLANS

potential needs prior to your admission. Planning continues
throughout the Hospital stay. Our purpose is to assist with prompt
discharge when it is medically appropriate and to explore
alternatives to continued Hospitalization. We may contract with
other companies to assist Us in discharge planning.

Second Opinion Program - We may require members to get a
Second Opinion for various inpatient and outpatient procedures.
We provide the names of Network Specialists who can offer a
Second Opinion. When a Member meets specific medical criteria,
We may waive the Second Opinion requirement.

Privileging - We have established limitations on the range of
services for which Network Providers may be paid. These payment
policies may be based, among other things, on the Network
Providers license and area of specialty. We may establish or
change privileging requirements for other services during your
enrollment.

Review of Utilization Patterns, Upcoding and Fraud
initiatives - We may conduct reviews of Network Provider
utilization practices to assess over- and under-utilization in
treatment practices, as well as a physicians compliance with
performance of effectiveness of care measures as required by
monitoring or regulatory agencies such as the National Committee
on Quality Assurance (NCQA), Departments of Health or other
agencies. Oxford may establish or change its focus or definition of
practice pattern assessment during your enrollment.

Oxford may monitor unusual billing, treatment or referral patterns.
Such monitoring is expected to enable Us to take action to address
potential over- and under-billing by Network Providers. Such
actions can include but are not limited to discussion with providers
about appropriate billing, treatment and referral, review of medical
records by Oxford or external experts, attempts to collect past
overpayments, imposition of Withholds, fee reduction or other
actions. Where required or appropriate, Oxford refers
inappropriate billing or treatment to applicable government
authorities.

Quantity Level Limits - In conjunction with our pharmacy benefits
management company, we have established quantity level limits
for coverage of the dosage of certain prescription drugs. We may
establish or change quantity level limits during your enrollment.

Precertification - Precertification enables Us to review the Medical
Necessity of a proposed service or treatment including the
determination of a proposed site of care, manage benefit
limitations, and whether the service will be performed by Network
Providers. Precertification allows Us to notify the Member or the
Members Provider regarding coverage before the service is
provided. In addition, it also allows Us to suggest appropriate and
cost effective sites for the proposed service/treatment. We may
establish or change precertification requirements during your
enrollment.

Referral Management - We use referral management to assess
how effective our PCPs and Specialists are at providing various
services. We record demographic and referral information from
each referral and use the data to monitor referral patterns

individually and on an aggregate basis. This allows Us to identify
patterns of care and quality issues to manage costs and to make
improvements in the quality of healthcare delivery. We may
establish or change referral processes during your enrollment.

Behavioral Health Case Management - Members and PCPs may
call Oxford at 800-201-6991 to obtain a referral for Mental Health
and Substance Abuse services. The Behavioral Health Line is
staffed by clinical professionals equipped to answer questions
regarding Mental Health and Substance Abuse benefits. These
professionals can also refer Members to an appropriate Network
Provider and they can Precertify these services as necessary.
Behavioral health services are subject to concurrent review and
discharge planning.

D. ADDITIONAL UTILIZATION MANAGEMENT
FUNCTIONS

Oxford has contracted with certain provider groups and
management companies to perform certain utilization management
functions. These include:

Precertification of Imaging Services: Oxford has contracted with
a company to assist Oxford in performing Precertification of
imaging services. Payment to Network Providers who contract with
the network manager is, in part, dependent on the volume of
radiology services provided to Members. The company may have a
financial incentive to contain the annual aggregate cost of imaging
services. In addition, Network Providers will be paid only for certain
imaging procedures, based on their specialty. All denials of
precertification for imaging services are made by an Oxford
Medical Director and appeals of denials may be made directly to
Oxford in accordance with our established appeals process.

Review of Orthopedic, Therapy, Subacute Care, and Chiropractic
Services: Oxford has contracted with companies to perform review
of orthopedic, podiatry, physiatry, therapy, subacute care and
chiropractic services. These companies may have a financial
incentive to contain the annual aggregate cost of services.
Appeals of denials may be made directly to Oxford

Informal Subnetwork: Oxford has contracted with IPAs (either on
a Capitation or Incentive basis) that have formed informal
subnetworks within the Oxford network. Network Providers who
participate in an informal subnetwork can ordinarily be expected to
refer Members for care to other Network Providers who participate
in the same informal subnetwork. IPAs or their affiliates may
perform utilization review functions and make coverage or payment
recommendations to Us. Our determination of coverage, directly or
on appeal, is separate from any such review activities. These IPAs
may have a financial incentive to contain the annual aggregate cost
of services. Members may however, obtain Covered Services on
an In Network basis from other Network Providers.

Pharmacy Services: Our pharmacy benefit management
company performs review of quantity and dosing guidelines for
certain drugs in accordance with policies adopted by Our
Pharmacy & Therapeutics Committee. In addition, certain drugs
require Precertification.

OXFORD HEALTH PLANS

Please note: Our utilization management programs, policies, and
procedures may change, and the companies with which we
contract to perform these services may also change during your
enrollment.

PART III
QUALITY MANAGEMENT

Our Quality Management (QM) Program promotes the provision of
quality health care and service for all OHP members.

Our QM Program identifies and pursues opportunities for
improvement of care and service and provides a structure for
documentation, tracking and reporting of these activities and
identified problem areas across the organization and to the Board
of Directors via the QM committee structure. This purpose is
accomplished by:

Identifying the scope of care and service provided through a
systematic and methodical process focused on areas of care
and service relevant to our member population;
Developing clinical guidelines, practice guidelines, and service
standards by which performance is measured taking into
consideration prudent medical practice and widely accepted
guidelines relevant to the clinical area;
Periodically reviewing the medical qualifications of
participating providers as required through regulatory
mandated as well as various accreditation standards;
Pursuing opportunities to improve access to health care,
continuity and coordination of care, and customer service
through compilation and analysis of various data including but
not limited to: claims payment, member complaint/appeal
information, provider practice patterns, and population-based
outcome studies.
Resolving identified quality issues, including follow-up on
individual circumstances, through peer review processes and
implementation of corrective action plans.

The QM Programs goals are to improve and/or maintain quality
patient services through ongoing monitoring and assessment of:

Provider compliance with recommended clinical treatment
guidelines in the delivery of care through various mechanisms
such as the annual HEDIS data collection, ongoing review of
provider medical records, analysis of Disease Management
outcomes and through other QM studies.
Member and Provider satisfaction.
Mechanisms to avoid adverse impact on quality of care
resulting from Our cost-containment programs.
Systematic education and outreach to Our providers and
members to facilitate their involvement in quality improvement
activities.
Definition and implementation of processes for the adequate
oversight of delegated functions.

We will periodically evaluate the effectiveness of individual quality
improvement initiatives in addition to the effectiveness of the
program as a whole.

Credentialing/Recredentialing

Credentialing Committees: Oxford has Credentialing
Committees in each regional office. Each committee is headed by
the Regional Medical Director. At regular meetings, the Committee
reviews applications and credentials of provider applicants.

Credentialing Requirements: In addition to meeting Our facility
and records standards, physicians or providers participating in our
HMO plans must generally meet the following (depending on
specialty) credentialing requirements to be an Oxford Network
Physician or Provider:

Current, valid state license to practice;
Current, valid DEA certificate;
Proof of board certification or recent (5 years from completion
of training) board eligibility, unless an exception to this
requirement has been granted;

Admitting privileges at a Network Hospital; unless an exception to
this requirement has been granted.

We also review information and representations furnished by the
physician or provider regarding: physical and mental health status;
lack of impairment from chemical dependency or substance abuse;
and malpractice history. Providers participating with Our HMO
plans are generally recredentialed every three years. We have
contracted with a third party vendor that verifies credentialing
requirements for Us.

Physicians and providers located outside the service areas of our
HMO plans, but which are network providers in our PPO plans, are
not subject to the same credentialing requirements as providers in
HMO plans. Physicians and providers participating in PPO plans
may be subject only to credentialing requirements of provider
organizations that contract with Oxford.

Credentialing requirements and processes may change during your
enrollment.

Provider Discipline Policies and Procedures

Our Provider Discipline Policies and Procedures apply to all
Providers affiliated with Us. Problems that may indicate the need
for discipline include, but are not limited to:

Quality of care concerns
Noncompliance with utilization, quality or other program
guidelines
Unsatisfactory utilization management

Depending on the nature and severity of the situation, we may
issue a warning, require a corrective action plan, reduce their fees,

OXFORD HEALTH PLANS

require pre-certification of additional services, reduce or suspend a
Providers privileges or formally terminate their participation with
Us. Disciplinary actions related to quality or utilization issues may
be started based on the recommendation of the Vice President for
Medical Affairs, Our Medical Director, or any of the Quality
Management committees or subcommittees. Disciplinary actions
related to administrative issues may be started by referral from any
department in the company to the Administrative Management
Committee.

Disciplinary actions that result in suspension for more than thirty
(30) days or termination resulting from a finding of professional
misconduct will be reported to the New York Department of Health,
Office of Professional Medical Conduct, as required by law.

OXFORD HEALTH PLANS
MS-04-151 1 Privacy 10/04
NOTICE TO OXFORD HEALTH PLANS
MEMBERS REGARDING OXFORDS PRIVACY
PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN
ACCESS THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
Oxford Health Plans LLC (Oxford) is committed to maintaining the
privacy and confidentiality of your protected health information
(PHI). PHI is information about you that is used or disclosed by
Oxford to administer your insurance coverage and to pay for the
medical treatment you receive. It includes demographic
information, such as your name, address, telephone number and
Social Security number, and any medical information obtained from
you or from providers who submit claims to Oxford related to your
medical care. We are required by applicable federal and state laws
to maintain the privacy of your PHI. This document serves as the
required Notice of Oxfords privacy practices, our legal duties, and
your rights concerning your PHI. Oxford is required to abide by the
terms of this Notice unless and until it is amended. This Notice
takes effect April 14, 2003, and will remain in effect until such time
that it is amended or replaced.
Oxford reserves the right to change our privacy practices and the
terms of this Notice at any time, provided that applicable law
permits such changes. We reserve the right to make the changes in
our privacy practices and the new terms of our Notice effective for
all PHI that we maintain, including information we created or
received prior to any such changes. When Oxford makes a
significant change in our privacy practices, we will revise this Notice
and send the revised Notice to our health plan subscribers.
For additional copies of this Notice, please call our Customer
Service Department at the toll-free number on your Oxford ID
card, or visit our web site at www.oxfordhealth.com.
Q. How does Oxford use or disclose your PHI?
A. Oxford may use or disclose your PHI, without your consent or
authorization, under the following circumstances:
Treatment: We may disclose your PHI to a healthcare
provider who requests it in order to provide you with
necessary medical treatment, such as emergency care, X-
rays or lab work. A provider might be a doctor, a hospital, a
home healthcare agency, etc.
Payment: We may use or disclose your PHI to pay claims
submitted by a healthcare provider for treatment provided to
you. For example, we may ask a hospital emergency
department for details about the treatment you received so
that we can accurately pay the hospital for your care.
Healthcare Operations: We may use or disclose your PHI to
manage our business. Examples include using it to
determine appropriate premiums, to conduct quality
improvement activities, to contact you regarding benefits or
services that might be of interest to you, and to provide you
with preventative health advisories.
Plan Sponsor: We may disclose limited PHI to your health
plan sponsor, benefits administrator, or group health plan in
order to perform plan administrative functions such as
activities related to billing and renewals.
Underwriting: We may receive your PHI for underwriting,
premium rating or other activities relating to the creation,
renewal or replacement of a contract of health insurance or
health benefits. Once an Oxford Member, use and
disclosure of your PHI is governed by this Notice.
Marketing: We may use your PHI to contact you with
information about health-related benefits and services,
treatment alternatives, or appointment reminders.
Research; Death; Organ Donation: In limited circumstances,
we may use or disclose your PHI for research purposes or
to a coroner, medical examiner, funeral director or an organ
procurement center.
Required by Law: We may use or disclose your PHI when
we are required to do so by law. For example, upon
request, we would disclose PHI to the U.S. Department of
Health and Human Services so that this agency can verify
Oxford compliance with federal privacy laws.
Health Oversight Activities: We may disclose your PHI to
health oversight organizations and agencies as part of
accreditation surveys, investigations related to our eligibility
for government programs, regulatory audits, and for
licensure and disciplinary actions.
Workers Compensation: We may disclose your PHI to
comply with laws relating to workers compensation or other
similar programs that provide benefits for work-related
injuries or illnesses.
Public Health and Safety: We may disclose your PHI to the
extent necessary to avert an imminent threat to your safety
or the health or safety of others. We may disclose your PHI
to appropriate authorities if we have reasonable belief that
you might be a victim of abuse, neglect, domestic violence,
or other crimes.
Judicial and Administrative: We may disclose your PHI in
response to a court or administrative order, subpoena,
discovery request, or other lawful process.
Sale of Business: We may disclose PHI upon sale of all or
part of Oxfords business to another party.
Law Enforcement: We may disclose limited information to
law enforcement officials concerning the PHI of a suspect,
OXFORD HEALTH PLANS
MS-04-151 2 Privacy 10/04
fugitive, material witness, crime victim or missing person.
Under certain circumstances, we may disclose the PHI of
an inmate or other person in lawful custody of a law
enforcement official or correctional institution.
Military and National Security: Under certain circumstances,
we may disclose the PHI of armed forces personnel to
military authorities. We may disclose PHI to authorized
federal officials when required for national security or
intelligence activities.
To Family and Friends: If, in the event of a medical
emergency, you are unable to provide any required
authorization, we may disclose PHI to a family member,
friend or other person to the extent necessary to ensure
appropriate medical treatment or to facilitate payment for
that treatment.
Q. Does Oxford ever need an authorization to use or disclose
your PHI?
A. Yes. Except for the purposes described above, Oxford cannot
use or disclose your PHI without a signed authorization from you. If
you provide such an authorization to Oxford, you may revoke it at
any time. Your revocation will not affect any use or disclosure of
PHI made while the authorization was in place.
Q. Can you inspect or receive copies of any PHI in Oxfords
possession?
A. Yes. You have the right to inspect or receive copies of your PHI
with certain exceptions. You must make a request to Oxford in
writing. Oxford reserves the right to charge a reasonable fee for the
cost of producing and mailing the PHI. Request forms are available
on the Oxford web site or by calling the number listed at the end of
this Notice.
Q. Can you find out if Oxford disclosed your PHI to a third
party?
A. Yes. You have the right to receive an accounting of all occasions
when Oxford disclosed your PHI for any purpose other than
treatment, payment, healthcare operations and certain other
instances. Beginning with disclosures made on or after April 14,
2003, we will maintain a record of disclosures for six (6) years. A
request for an accounting must be submitted to Oxford in writing.
We reserve the right to charge you a reasonable fee for the cost of
producing and mailing the information if you request this accounting
more than once in a 12-month period. Please note, that
Connecticut and New Jersey members will automatically get an
abridged accounting whenever they make a request to inspect or
receive copies of their PHI.
Q. Can you restrict the use or disclosure of your PHI by
Oxford?
A. Yes. You have the right to request that Oxford place additional
restrictions on the use or disclosure of your PHI. We are not
required by law to agree to these restrictions. However, if we do
agree to the restrictions, we will abide by them except in the event
of an emergency.
Q. Can you request that Oxford use alternate means to
confidentially communicate with you about your PHI or
communicate with you at an alternate location?
A. Yes. You must inform Oxford, in writing, that confidential
communication by alternate means or to an alternate location is
required to avoid potential harm to yourself or others. We must
accommodate your request if it is reasonable, specifies the
alternate communication means or location, and does not interfere
with the collection of premiums, the payment of claims, or the
administration of your health insurance coverage.
Q. Do you have the right to request that Oxford correct,
amend, or delete your PHI?
A. Yes. You must make your request in writing, and it must explain
why the PHI should be corrected, amended, or deleted. Oxford may
deny your request if we did not create the PHI in question or for
certain other reasons. If we deny your request, we will provide you
with a written explanation. You may respond with a statement of
disagreement to be added to the information you sought to change.
If we accept your request to correct, amend, or delete the PHI, we
will make reasonable efforts to inform others of the changes and to
include the changes in any future disclosures of that information.
Complaints
To express concern about a decision Oxford made about access to
your PHI, to report a concern that we violated your privacy rights, or
to express a complaint about any aspect of Oxfords privacy
practices, please contact the HIPAA Member Rights Unit at the
address below. You may also submit a written complaint to the
Secretary of the U.S. Department of Health and Human Services at
the following address:
Office of the Secretary
Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Telephone: 877-696-6775
Oxford supports your right to protect the privacy of your PHI and
will not retaliate against you for filing a complaint with any
government regulatory body or with us.
If you received this Notice on our web site or by electronic mail (e-
mail), you are entitled to receive a written copy of the Notice as
well. To request a written copy of the Notice, please call our
Customer Service Department at the toll-free number on your
Oxford ID card, or call 800-444-6222. You can also contact us by
mail at:
HIPAA Member Rights Unit
Oxford Health Plans
48 Monroe Turnpike
Trumbull, CT 06611
OXFORD HEALTH PLANS
MS-04-151 3 Privacy 10/04
All written communications related to this Notice and your rights
under HIPAA should be mailed to the HIPAA Member Rights Unit at
the address above.
Privacy Notice Concerning Financial Information
At Oxford Health Plans LLC ("Oxford"), protecting the privacy of the
personal information we have about our customers and members is
of paramount importance and we take this responsibility very
seriously. This information must be and is maintained in a manner
that protects the privacy rights of those individuals. This notice
describes our policy regarding the confidentiality and disclosure of
customer and member personal financial information that Oxford
collects in the course of conducting its business. Our policy applies
to both current and former customers and members.
The Information Oxford Collects
We collect non-public, personal financial information about you
from the following sources:
Information we receive from you on applications or other forms
(such as name, address, social security number and date of
birth.)
Information about your transactions with us, our affiliates
(companies controlled or owned by Oxford), or others; and
Information we receive from consumer reporting agencies
concerning large group customers.
The Information Oxford Discloses
We do not disclose any non-public, personal financial information
about our current and former customers and members to anyone
except as permitted by law. For example, we may disclose
information to affiliates and other third parties to service or process
an insurance transaction; or provide information to insurance
regulators or law enforcement authorities upon request.
Oxford Security Practices
We emphasize the importance of confidentiality through employee
training, the implementation of procedures designed to protect the
security of our records, and our privacy policy. We restrict access
to the personal financial information of our customers and members
to those employees who need to know that information to perform
their job responsibilities. We maintain physical, electronic, and
procedural safeguards that comply with federal and state
regulations to guard your non-public, personal financial information.
This notice is being provided on behalf of the following Oxford
affiliates:
Oxford Health Plans LLC
Oxford Health Plans (CT), Inc.
Oxford Health Plans (NJ), Inc.
Oxford Health Plans (NY), Inc.
Investors Guaranty Life Insurance Company
Oxford Benefit Management, Inc.
you would like a copy of these Notices in Spanish, please
contact Oxford Customer Service at the number on the back
of your Oxford Member ID card.
If you would like a copy of these Notices in Chinese, please
If you would like a copy of these Notices in Korean, please

Healthier members are
happier members.
Starting or staying with an exercise routine isnt always
easy. To help you stay motivated and achieve your ftness
goals, we provide reimbursement toward ftness center
membership fees.
1
You can get reimbursed for going to
the gym an average of two-to-three times per week. We
know that staying with an exercise routine isnt always
easy, and this can help you stay motivated and healthy.
Note: Tis reimbursement is not available to members of
all groups, including members within any Connecticut or
small group New Jersey plan.
Its easy. First, select a gym.
To receive reimbursement, you must participate in a gym
and/or program that promotes cardiovascular wellness.
(Memberships in sports clubs, country clubs, weight loss
clinics, spas, or other similar facilities are not eligible.)
For a gym to be considered eligible, it must provide at
least two pieces of equipment or activities tha t promote
cardiovascular wellness from the following list:
clliptical crosstraincr
group cxcrcisc
pool
rowing machinc
squash/tcnnis/
racquetball courts
stationary bicyclc
stcp machinc/climbcr
trcadmill
walking/running group
How much can you get reimbursed?
Please check your benefts documents or check with your
benefts administrator to determine how much you (and
your spouse or domestic partner) may be reimbursed.
2

Te reimbursement period begins on the date of your
initial visit to the gym and ends six months from that
date. Subsequent reimbursement periods begin one day
after your previous reimbursement period ended.
3
You should follow the steps below
to receive reimbursement for your
tness participation:
1. Visit the gym You must complete a minimum of 50
visits per six-month period. Reimbursements will not
be issued until six months have passed, even if 50 visits
are completed sooner than six months.
2. Collect paperwork You need to collect three things: a
copy of your current gym bill, showing the monthly
cost of your membership; proof of payment for each of
the six months you are submitting for reimbursement
(i.e., credit card statement, payroll deduction, automatic
bank withdrawal, etc.)
4
; and a copy of the brochure that
outlines the services the gym ofers.
3. Complete the form Fill out and submit a Gym
Reimbursement Form, which is shown on the reverse
side of this page. Remember to provide the dates of
your gym visits completed within the six-month period
for which you are making a claim. Also, a representative
from your gym must sign the form. You can get extra
forms from your benefts administrator, from our
website www.oxfordhealth.com or by calling Customer
Service at the telephone number on your Oxford
member ID card.
4. Mail everything Te Gym Reimbursement Form,
along with a copy of your current gym bill, proof of
payment and a copy of the gyms brochure should
be submitted within six months (180 days) to the
following address:
Oxford Gym Reimbursement
P.O. Box 7082
(Phone: 1-800-444-6222)
Important: Please complete the form in its entirety, or the
processing of your claim may be delayed or denied. Please
complete one form per member, for each six-month
period for which you are making a claim.
Gym Reimbursement
The only thing better than staying in shape is getting reimbursed for it.
1
Check your Certifcate of Coverage to determine eligibility for this reimbursement.
2
Te reimbursement beneft is limited to you and your spouse or domestic partner; no other dependents are eligible. For your spouse or
domestic partner to be eligible for this beneft, he or she must also be enrolled in an Oxford product. Reimbursement amounts may vary
depending upon your plan. Please refer to your Certifcate of Coverage/health benefts plan documents to confrm your policys beneft.
3
Please refer to your Certifcate of Coverage/health benefts plan documents to confrm your policys beneft and for applicable fling
deadlines. Claim must be fled upon completion of the six-month period being submitted in order to obtain reimbursement.
4
On your proof of payment, please be sure to cross out your personal account identifcation information and other information not
relevant to your gym payment so it is not legible.

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Gym Reimbursement Form
Member name: __________________________________________ Member address: __________________________________
Oxford member ID number: ________________________________ Date of birth: _____________________________________
Six-month period requested: Start date: _________________________ End date: ____________________________________
Dates of your 50 gym visits*:
* As a substitute for flling in the dates of your 50 gym visits on this form, you may submit one of the pieces of documentation
that are listed below as an attachment to this form. Your documentation must include a signature from a gym representative for
verifcation purposes.
- A photocopy of your tness program card or your records kept on le at the gym.
An original signature must appear on the photocopy (photocopied signatures are not valid);
- A computer printout of your visits to the tness center;
- Receipts that indicate each time you have visited the gym; or
- Verication from your employer that indicates your use of the employer's gym.
Name of facility: ________________________________________ Facility employee's signature: __________________________
Facility employee's signature above constitutes agreement that the facility promotes cardiovascular wellness for members. False statements will result in the denial of
reimbursement. My signature below arms that all of the information listed above is full, complete and true to the best of my knowledge.
Member signature: _________________________________________________________ Date: ___________________________
Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc. and Oxford Health Plans (NJ), Inc. Oxford insurance
products are underwritten by Oxford Health Insurance, Inc. 2010 Oxford Health Plans LLC.
MS-10-621 8904 R4
If you have any questions regarding gym
reimbursement, please call Customer Service
at 1-800-444-6222.
MS-03-420 6246 Access Request Form 1.11

ACCESS REQUEST FORM
Purpose: This Form is intended for use by an individual to exercise his/her right to access his/her protected health
information in Oxfords designated record sets or the designated record sets of Oxfords business associates.
Individual Seeking Access
Name:
Address:
Oxford I.D. Number:
Telephone:
Scope of Access
You have the right to inspect and obtain a copy of your protected health information maintained by Oxford and its
business associates. You are not, however, entitled to inspect or obtain a copy of any psychotherapy notes we may have
or any information we may have compiled in anticipation of or for use in any civil, criminal or administrative action or
proceeding.
Please specify the records you wish to inspect or obtain copies of:

We may charge you to make copies and mail your protected health information. Oxford will notify you in advance of
these charges. If you want to pick the copies up at our Trumbull, CT office please check here
Signature: Date:

Personal Representative
If this request is being made by a personal representative on behalf of the individual, please provide a description and
any available documentation of authority to act as the individuals personal representative and sign below.

Print name
Signature

Please send completed form to:

Oxford Health Plans
Attn: HIPAA Member Rights Unit
P.O. Box 7081

YOU ARE ENTITLED TO A COPY OF THIS REQUEST.
OXFORD HEALTH PLANS
______

OHINY R BU VIS LS 109 NY OHI EPO Vision Rider w Hardware 4.09

Vision Care

Your Certificate is revised by adding the following
language in the Supplemental Coverage section:

Vision Care

Covered Benefits

Within one 24-month period, We will reimburse you the amount
shown in your Summary of Benefits for one set of appliances per
Member. The 24-month period commences with the Members
initial use of this benefit.

Covered Benefits

Within one 12-month period, one vision exam per Member
including refraction will be covered subject to the amount shown in
your Summary of Benefits. All services are also subject to any
applicable Plan Deductibles, as shown on your Summary of
Benefits.

IV. Miscellaneous Provisions

This Rider supersedes any amendment, Certificate language or
rider providing coverage for Vision Care previously issued by Us.
In the event of a conflict between the provisions of this Rider and
the Certificate or any other document, the provisions of this Rider
will prevail. All other terms and conditions of the Certificate remain
in full force and effect.

Nothing contained in this Rider will be held to vary, alter, waive, or
extend any of the terms, conditions, provisions or limitations of the
Agreement to which this Rider is attached, other than as
specifically stated herein.

OXFORD HEALTH PLANS

OHINY R S RX 309 1 OHINY_SM_RXNYS635ET_1012
Outpatient Prescription
Drug Rider

This Rider has been selected by your Group and provides benefits
for outpatient Prescription Drug Products. Because this Rider is
part of a legal document, We want to give you information about
the document that will help you understand it. Certain capitalized
words have special meanings. We have defined these words in the
Definitions Section of your Certificate of Coverage as well as the
Definitions Section of this Rider.

When We use the words We, Us, and Our in this document,
We are referring to Oxford Health Insurance, Inc. When We use
the words you and your We are referring to Members as the
term is defined in your Certificate of Coverage.

Section 1 - Covered Items

Subject to the Exclusions in Section 4 of this Rider, the cost of
Medically Necessary Prescription Drug Products will be Covered if
they are FDA approved, ordered by a Physician, within the
approved FDA administration and dosing guidelines and are
dispensed by a Pharmacy. Benefits are available for Prescription
Drug Products on our Prescription Drug List at a Network
Pharmacy. Coverage may be available at a non-Network
Pharmacy if your Group has purchased this coverage. Covered
Prescription Drug Products will be subject to the Out-of-Pocket
Expense identified on your Summary of Benefits. Please refer to
your Summary of Benefits to determine your Out-of-Pocket
Expense and whether coverage is available at non-Network
Pharmacies.

Covered Prescription Drug Products include, but are not limited to:
Self-injectible Prescription Drug Products
Inhalers (with spacers)
Topical dental preparations
Pre-natal vitamins, vitamins with fluoride and single entity
vitamins
Prescription osteoporosis drugs and devices approved by the
FDA for the treatment of osteoporosis
Nutritional supplements (formulas) for the therapeutic
treatment of phenylketonuria, branched-chain ketonuria,
galactosemia and homocystinuria
Non-prescription enteral formulas for home use for which a
Physician has issued a written order. The written order must
state that the enteral formula is Medically Necessary as a
disease-specific treatment regimen for diseases which include
but are not limited to: inherited diseases of amino acid or
organic acid metabolism; Chrons disease; gastroesophageal
motility such as chronic intestinal pseudo-obstruction; and
multiple severe food allergies. Nutritional supplements that
are taken electively are not Covered.
Modified solid food products that are low in protein or which
contain modified protein are Covered, when Medically
Necessary to treat certain inherited diseases of amino acid
and organic acid metabolism not to exceed the maximum
listed on your Summary of Benefits.
Prescription Drug Products for the treatment of correctible
medical conditions which result in infertility will be Covered at
the same level as benefits for any other sickness.

Refills of Prescription Drug Products are Covered only when
dispensed as ordered by a Physician and only after of the
original Prescription Drug Product has been used.

Section 2 Benefit Information

1. Out-of-Pocket Expenses: You are responsible for paying
the costs outlined in your Summary of Benefits when Covered
Prescription Drug Products are obtained from the retail
pharmacy or mail order supplier (if mail order coverage has
been purchased). Please refer to your Summary of Benefits
to determine if your Plan includes coverage for mail order.

Unless otherwise stated in your Summary of Benefits, these
costs will not be included in calculating the Plan Out-of-
Pocket Maximum stated in your Summary of Benefits.

You are responsible for paying the full cost (the amount the
pharmacy charges you) for any non-Covered drug product,
and Our contracted rates (Our Prescription Drug Cost) will not
be available to you.

Out-of-Pocket Expenses for a Covered Prescription Drug
Product can be either a specific dollar amount or a
percentage of the Prescription Drug Cost. Out-of-Pocket
Expenses are determined by the type of Plan your Group has
purchased, as follows:
If you have a single option plan design, you will pay the
same Out-of-Pocket Expense for all Covered Prescription
Drug Products.
If you have a dual option plan design, you will have a
lower Out-of-Pocket Expense for Generic Drugs and a
higher Out-of-Pocket Expense for Brand-Name Drugs.
If you have a triple tier plan design, your Out-of-Pocket
Expense will be lowest for Prescription Drug Products on
Tier 1 and highest for Prescription Drug Products on Tier
3. Your Out-of-Pocket Expense for Prescription Drug
Products on Tier 2 will be more than for Tier 1 but less
than Tier 3.

Please see your Summary of Benefits for the Out-of-Pocket
Expenses required as part of your Prescription Drug Plan and
to determine if your Plan includes coverage at non-Network
Pharmacies.

2. Network Pharmacies: For Prescription Drug Products at a
retail Network Pharmacy, you are responsible for paying the
lower of:
the applicable Out-of-Pocket Expense; or
the Network Pharmacys Usual and Customary Charge
(which includes a dispensing fee and sales tax) for the
Prescription Drug Product.
OXFORD HEALTH PLANS


You must either show your ID card at the time you obtain your
Prescription Drug Product at a Network Pharmacy or you must
provide the Network Pharmacy with identifying information that
can be verified by Us during regular business hours.

If you do not show your ID card or provide verifiable
information at a Network Pharmacy, you will be required to
pay the Usual and Customary Charge for the Prescription
Drug Product at the pharmacy. You may seek reimbursement
from Us, however when you submit a claim on this basis, you
may pay more because you failed to verify your eligibility when
the Prescription Drug Product was dispensed. The amount
you are reimbursed will be based on the Prescription Drug
Cost, less the required Out-of-Pocket Expense identified on
your Summary of Benefits.

In the event that no Network Pharmacy is able to provide the
Covered Prescription Drug Product, and cannot order the
Prescription Drug Product within a reasonable time, you may,
with Our prior written approval, go to a non-Network Pharmacy
that is able to provide the Prescription Drug Product. We will
pay you the Prescription Drug Cost for such approved
Prescription Drug Product less the required Out-of-Pocket
Expense upon receipt of a Prescription Drug Claim form.

3. Non-Network Pharmacies: If your Plan includes coverage
for Prescription Drug Products purchased at a retail non-
Network Pharmacy you must pay for the Prescription Drug
Product at the time it is dispensed and then file a claim for
reimbursement with Us. We will not reimburse you for the
difference between the Prescription Drug Cost and the non-
Network Pharmacys Usual and Customary Charge (which
includes a dispensing fee and sales tax) for that Prescription
Drug Product. In most cases you will pay more if you obtain
Prescription Drug Products from a non-Network Pharmacy.
Please refer to your Summary of Benefits to determine if you
have coverage at a non-Network Pharmacy.

4. Designated Pharmacies: If you require certain Prescription
Drug Products, including, but not limited to, Specialty
Prescription Drug Products, we may direct you to a
Designated Pharmacy with whom we have an arrangement to
provide those Prescription Drug Products.

If you are directed to a Designated Pharmacy and you choose
not to obtain your Prescription Drug Product from a
Designated Pharmacy, you will not have coverage for that
Prescription Drug Product or your coverage will be subject to
the non-Network Benefit for that Prescription Drug Product (if
available). Please refer to your Summary of Benefits
document to determine if you have non-Network benefits for
Prescription Drug Products.

Following are the therapeutic classes of Prescription Drug
Products that will be included in this program:
Hepatitis B, Hepatitis C
Multiple Sclerosis
Rheumatologic and related conditions
(Rheumatoid Arthritis, Psoriatic Arthritis,
Ankylosing Spondylitis, Juvenille
Rheumatoid Arthritis, Psoriasis)
Growth Hormone
Anemia, neutropenia, thrombocytopenia
Infertility
HIV/AIDS
Transplant
Oral Oncology
Pulmonary Arterial Hypertension
Osteoporosis
Cystic Fibrosis
Gaucher's Disease
Iron Overload
Endocrine disorders/Neurologic disorders
such as infantile spasms
Hemophilia
Enzyme Deficiencies/Liposomal Storage
Disorders
Immune Modulator
Immune Deficiency
Parkinson's Disease
5. Tier Status: The tier status of a Prescription Drug Product
may change periodically. Changes will generally be quarterly,
but no more than six times per Calendar Year, based on the
PDL Management Committees periodic tiering decisions.
When such changes occur, your Out-of-Pocket Expense may
change. You may access the most up to date tier status on
Our web site or by calling the Customer Care number on your
ID card.

6. Supply Limits: Benefits for Prescription Drug Products are
subject to the supply limits that are stated in your Summary of
Benefits. Some Prescription Drug Products may be subject to
additional quantity limits based on criteria that We have
developed, subject to Our periodic review and modification.
The limit may restrict the amount dispensed per Prescription
Order or Refill and/or the amount dispensed per months
supply.

Additionally, certain Prescription Drug Products may be
designated as eligible for Our voluntary half tablet program.
This program provides the opportunity to reduce your
Prescription Drug Product Out-of-Pocket Expenses by up to
50% by using higher strength tablets and splitting them in half.
If you are taking an eligible Prescription Drug Product, and
you would like to participate in this program, please call your
OXFORD HEALTH PLANS

Physician to see if the half tablet program is appropriate for
your condition. If your Physician agrees, he or she must write
a new prescription for your medication to enable your
participation.

You can determine whether a Prescription Drug Product has
been assigned a maximum quantity level for dispensing or is
eligible for the voluntary half tablet program by accessing Our
web site or by calling Customer Care at the telephone number
on your ID card.

7. Mail Order: Certain Prescription Drug Products may be
ordered through Our mail order supplier if your Group has
purchased this coverage. If your Group has purchased mail
order coverage, you are responsible for paying the lower of:
the applicable Out-of-Pocket Expense; or
the Prescription Drug Cost for that Prescription Drug
Product.

Prescription Drug Products purchased through mail order will
be delivered directly to your home or office. You must pay the
applicable Out-of-Pocket Expense listed on your Summary of
Benefits. The required Out-of-Pocket Expense will be based
on a 90-day supply. To maximize your benefit, ask your
Physician to write your Prescription Order or Refill for a 90-day
supply with refills when appropriate. You will be charged the
mail order Out-of-Pocket Expense for any Prescription Orders
or Refills sent to the mail order supplier regardless of the
number of days supply written on the Prescription Order or
Refill. Be sure your Physician writes your Prescription Order
or Refill for a 90-day supply, not a 30-day supply with three
refills.

Please refer to your Summary of Benefits to determine if your
Plan includes coverage for mail order.

8. When a Brand Name Drug Becomes Available As a
Generic: When a Generic becomes available for a Brand
Name Prescription Drug Product, the tier placement of the
Brand Name Prescription Drug Product may change. If this
happens, you will pay the Out-of-Pocket expense applicable
for the tier to which the Prescription Drug Product is assigned
as outlined on your Summary of Benefits.

Section 3 Terms of Coverage

1. Tier Structure: Our Prescription Drug List (PDL)
Management Committee is authorized to make tier placement
changes on Our behalf. The PDL Management Committee
makes the final classification of an FDA-approved Prescription
Drug Product to a certain tier by considering a number of
factors, including, but not limited to, clinical and economic
factors regarding Members as a general population. Whether
a particular Prescription Drug Product is appropriate for an
individual Member is a determination that is made by the
Member and the prescribing Physician. Clinical factors may
include, but are not limited to, evaluation of the place in
therapy, relative safety or relative efficacy of the Prescription
Drug Product, as well as whether supply limits or
Precertification requirements should apply. Economic factors
may include, but are not limited to, available rebates, and
assessments on the cost effectiveness of the Prescription
Drug Product.

The tier status of a Prescription Drug Product may change
periodically. Changes will generally be quarterly, but no more
than six times per Calendar Year, based on the PDL
Management Committees periodic tiering decisions. These
changes may occur without prior notice to you. As a result of
such changes you may be required to pay more or less for
that Prescription Drug Product. Please access Our web site
or call the Customer Care number on your ID card for the
most up to date tier status.

2. Precertification: Certain Prescription Drug Products will be
Covered in accordance with Our applicable Medical Policy if
they are determined by Us to be Medically Necessary for their
intended use as evidenced by the advance written approval
of Our Medical Director. The Prescription Drug Products
that require Precertification on the attachment titled
Prescription Drug Products Requiring Precertification. This
information is also available through the Internet at
www.myuhc.com or by calling Customer Care at the
telephone number on your ID card.

We also reserve the right to require Precertification for any
new drug on the market or of any currently available drug
which undergoes a change in prescribing protocols and/or
indications regardless of the therapeutic classification.

In addition, certain Prescription Drug Products may be
designated as Step Therapy Drugs. This means that before
coverage for such Prescription Drug Product will be provided,
you must have tried one or more prerequisite Prescription
Drug Products. If it is Medically Necessary for you to use a
Step Therapy Drug as an initial medication, your Physician
can request initial coverage as a medical exception.
Confirmation of whether a drug is a Step Therapy Drug can
be obtained through Our web site or by calling Customer Care
at the number on your ID card.

To initiate the Precertification process, your Physician must
contact Us and provide all relevant clinical data. If
Precertification has been granted you will be responsible for
the applicable Out-of-Pocket Expense listed in your Summary
of Benefits. Should you choose to purchase the medication
without obtaining Precertification, you must pay for the cost of
the entire drug and submit a claim to Us for reimbursement.
Claims for reimbursement of such drugs will be subject
to a Precertification penalty of 50%.

3. Limitation on Selection of Pharmacies: If We determine
that you may be using a Prescription Drug Product in a
harmful or abusive manner, or with harmful frequency, your
selection of Network Pharmacies may be limited. If this
happens, We may require you to select a single Network
Pharmacy that will provide and coordinate all future pharmacy
services. Benefits will be paid only if you use the designated
OXFORD HEALTH PLANS

single Network Pharmacy. If you dont make a selection
within 31 days of the date we notify you, we will select a
single Network Pharmacy for you.

4. Rebates and Other Payments to Us: We conduct various
utilization management activities designed to ensure
appropriate prescription drug usage, to avoid inappropriate
usage and to encourage the use of cost effective drugs.
Through these efforts, your Group and its members benefit by
obtaining appropriate prescription drugs in a cost-effective
manner. The cost savings resulting from these activities are
reflected in the premiums for your coverage. We may, from
time to time, also enter into agreements that result in Us
receiving rebates or other funds (rebates) directly or
indirectly from prescription drug manufacturers, prescription
drug distributors or others. Any rebates are based upon
utilization of Prescription Drug Products across all of Our
business and not solely on any on Members or Groups
utilization of Prescription Drug Products.

Any rebates received by Us may or may not be applied, in
whole or part, to reduce premiums either through an
adjustment to claims costs or as an adjustment to the
administrative expenses component of Our prescription drug
premiums. Any such rebates may instead be retained by Us,
at Our discretion, in whole or in part, in order to fund such
activities, including but not limited to, as new utilization
management activities, community benefit activities and
increasing reserves for the protection of subscribers. Rebates
will not change or reduce the amount of any Out-of-Pocket
Expenses applicable under Our prescription drug coverage.

Section 4 Exclusions

In addition to the Exclusions listed in your Certificate of Coverage,
the following are excluded from coverage under this Rider:

1. Prescription Drug Products obtained from a non-Network
Pharmacy, unless your Group has purchased such coverage.
Please refer to your Summary of Benefits to see if your Group
has purchased Out-of-Network coverage for Prescription Drug
Products.

2. Coverage for Prescription Drug Products for the amount
dispensed (days supply or quantity limit) which exceeds the
supply limit. Any prescription refilled in excess of the number
specified by the Physician; refilled too soon or in excess of
therapeutic limits; or any refill dispensed after one year from
the Physicians original order.

3. Prescription Drug Products dispensed outside of the United
States, including its possessions or the countries of Canada
and Mexico, except as required for Emergency treatment.

4. Drugs which are prescribed, dispensed or intended for use
while you are an inpatient in a Hospital, Skilled Nursing
Facility, or Alternate Facility.

5. Experimental or Investigational Services and medications;
medications used for experimental indications and/or dosage
regimens determined by Us to be experimental,
investigational or unproven unless approved by an external
appeal agent. Please see the Utilization Review Appeal
section of your Certificate for your appeal rights.

Important: If an External Appeal Agent approves coverage
of an experimental or investigational treatment that is part of a
clinical trial, We will only Cover the cost of services required
to provide treatment to you according to the design of the trial.
We will not be responsible for the costs of investigational
drugs or devices, the costs of non-health care services, the
costs of managing research, or costs which would not be
Covered under this Certificate for non-experimental or non-
investigational treatments provided in such clinical trial.

This exclusion does not apply to drugs for the treatment of
cancer that have not been approved by the Federal Food and
Drug Administration for that indication, if the drug has been
prescribed for a Member who has been diagnosed with
cancer, provided the drug is recognized for treatment of the
specific type of cancer for which the drug has been prescribed
in one of the following established reference compendia: (i)
the American Medical Association Drug Evaluations; (ii) the
American Hospital Formulary Service Drug Information; or (iii)
the United States Pharmacopeia Drug Information; or
recommended by review article or editorial comment in a
major peer reviewed professional journal.

This exception does not provide coverage for any
experimental or investigational drugs or any drug which the
Federal Food and Drug Administration has determined to be
contraindicated for treatment of the specific type of cancer for
which the drug has been prescribed.

6. Prescription Drug Products furnished by the local, state or
federal government. Any Prescription Drug Product to the
extent payment or benefits are provided or available from the
local, state or federal government (for example Medicare)
whether or not payment or benefits are received, except as
otherwise provided by law.

7. Prescription Drug Products for any condition, injury, sickness
or mental illness arising out of, or in the course of,
employment for which benefits are provided under any
Workers Compensation Law or other similar laws.

8. A specialty medication Prescription Drug Product (including,
but not limited to, immunizations and allergy serum) which,
due to its characteristics, as determined by Us, must typically
be administered or supervised by a qualified provider or
licensed/certified health professional in an outpatient setting.

9. Durable Medical Equipment. Prescribed and non-prescribed
outpatient supplies, other than inhaler spacers and drugs for
the treatment of osteoporosis specifically stated as Covered.

10. Unit dose packaging of Prescription Drug Products.
OXFORD HEALTH PLANS


11. Prescription Drug Products used for cosmetic purposes.
Please note, all denials for these items are based on Medical
Necessity. If coverage is denied, you are entitled to a

12. Prescription Drug Products, including new Prescription Drug
Products or new dosage forms that are determined to not be
a Covered Service.

13. Prescription Drug Products as a replacement for a previously
dispensed Prescription Drug Product that was lost, misued,
stolen, broken or destroyed.

14. Diabetic Equipment and Supplies. Coverage for diabetic
equipment and supplies is provided as part of your medical
benefits. Please refer to your Certificate of Coverage for an
explanation of these benefits.

15. Non-FDA approved legend drugs, non-legend drugs and
drugs available over-the-counter which do not require a
Prescription Order or Refill by federal or state law before
being dispensed. Any Prescription Drug Product that is
therapeutically equivalent to an over-the-counter drug unless
Medically Necessary. Prescription Drug Products that are
comprised of components available in Over-the-Counter form
or equivalent.

16. Compounded drugs that do not contain at least one ingredient
that requires a Prescription Order or Refill. Compounded
drugs that contain at least one ingredient that requires a
Prescription Order or Refill will be assigned to either Tier 2 or
Tier 3.

17. New Prescription Drug Products and/or new dosage forms
until the date they are reviewed and assigned to a tier by the
PDL Management Committee.

18. Vitamins, hematinics, minerals and supplements, even if
ordered by a Physician, unless specifically listed in the
Covered Items section of this Rider.

19. Charges for the administration or injection of any drug.

20. Immunization agents, biological sera, blood or blood plasma.

21. Allergens and allergy serums.

22. Oral and topical prescription antiseptics.

23. Prescription weight loss aids other than those used for the
treatment of morbid obesity. Weight loss drugs that are used
in the treatment of morbid obesity are automatically Covered
under the Prescription Drug Plan. Please note, all denials for
these items are based on Medical Necessity. If coverage is

24. Prescription Drug Products for smoking cessation. Please
note, all denials for these items are based on Medical
Necessity. If coverage is denied, you are entitled to a

25. Growth hormone for children with familial short stature (short
stature based upon heredity and not caused by a diagnosed
medical condition) unless Medically Necessary. If coverage is

Section 5 Definitions

This section defines the terms used throughout this rider. Other
defined terms used in this rider can be found in the Definitions
Section of your Certificate of Coverage. This section is not
intended to describe benefits.

Brand-Name: a Prescription Drug Product that (1) is
manufactured and marketed under a trademark or name by a
specific drug manufacturer; or (2) that We identify as a Brand-
Name Product, based on available data resources including, but
not limited to, First DataBank, that classify drugs as either brand or
generic based on a number of factors. You should know that all
products identified as a brand name by the manufacturer,
pharmacy, or your Physician may not be classified as Brand-Name
by Us.

Designated Pharmacy - a pharmacy that has entered into an
agreement with us or with an organization contracting on our
behalf, to provide specific Prescription Drug Products, including,
but not limited to, Specialty Prescription Drug Products. The fact
that a pharmacy is a Network Pharmacy does not mean that it is a
Designated Pharmacy.

Generic: a Prescription Drug Product that (1) is chemically
equivalent to a Brand-Name drug; or (2) that we identify as a
Generic product based on available data resources including, but
not limited to, First DataBank, that classify drugs as either brand or
generic based on a number of factors. You should know that all
products identified as a generic by the manufacturer, pharmacy,
or your Physician may not be classified as a Generic by us.

Network Pharmacy: a pharmacy that has:
entered into an agreement with us or our designee to provide
Prescription Drug Products to Members;
agreed to accept specified reimbursement rates for dispensing
Prescription Drug Products; and
has been designated by us as a Network Pharmacy.

A Network Pharmacy can be either a retail or home delivery
pharmacy for Plans that include coverage for mail order. Please
refer to your Summary of Benefits to determine if your Plan
includes coverage for mail order.

New Prescription Drug Product: a Prescription Drug Product or
new dosage form of a previously approved Prescription Drug
Product, for the period of time starting on the date the Prescription
Drug Product or new dosage form is approved by the FDA, and
ending on the earlier of the following dates:
the date it is assigned to a tier by our PDL Management
Committee; or
OXFORD HEALTH PLANS

December 31
st
of the following Calendar Year.

Prescription Drug Cost: the rate We have agreed to pay Our
Network Pharmacies, including a dispensing fee and any sales tax,
for a Covered Prescription Drug Product dispensed at a Network
Pharmacy. If your Plan includes coverage at non-Network
Pharmacies, the Prescription Drug Cost for a Prescription Drug
Product dispensed at a non-Network Pharmacy is calculated using
the Prescription Drug Cost that applies for that particular
Prescription Drug Product at most Network Pharmacies.

Prescription Drug List (PDL): the list that identifies those
Prescription Drug Products for which Coverage may be available
under this rider. This list is subject to Our periodic review and
modification (generally quarterly, but no more than six times per
Calendar Year). You may determine to which tier a particular
Prescription Drug Product has been assigned through Our web site
or by calling the Customer Care number on your ID card.

PDL Management Committee: the committee that We designate
for, among other responsibilities, classifying Prescription Drug
Products into specific tiers.

Prescription Drug Product: a medication, product or device that
has been approved by the Food and Drug Administration and that
can, under federal or state law, be dispensed only pursuant to a
Prescription Order or refill. A Prescription Drug Product includes a
medication that, due to its characteristics, is appropriate for self-
administration or administration by a non-skilled caregiver.

Prescription Drug Product does not include medical supplies,
drugs, medications, injections or intravenous therapies (i) provided
at a hospital; (ii) provided in connection with any home care benefit
under the Certificate; or (iii) that must be administered by a
physician or physician-supervised health professional.

Prescription Order or Refill: the directive to dispense a
Prescription Drug Product issued by a duly licensed health care
provider whose scope of practice permits issuing such a directive.

Usual and Customary Charge: the usual fee that a pharmacy
charges individuals for a Prescription Drug Product without
reference to reimbursement to the pharmacy by third parties.
OXFORD HEALTH PLANS

OHINY R BU PREV LS 512 7 OHINY_SM_RXNYS635EW_1012
Oxford Health Plans Insurance, Inc.
Patient Protection and
Affordable Care Act
(PPACA) Preventive Care
Medications Addendum
As described in this addendum, Benefits for Preventive Care
Medications described in the Outpatient Prescription Drug Rider
are modified as stated below.
Because this addendum is part of a legal document (the Group
Enrollment Agreement), we want to give you information about the
document that will help you understand it. Certain capitalized words
have special meanings. We have defined these words in the
Certificate of Coverage and in this addendum below.
Benefits for Preventive Care Medications
Benefits under the Outpatient Prescription Drug Rider include those
for Preventive Care Medications as defined below. You may
determine whether a drug is a Preventive Care Medication through
the internet at www.myuhc.com or by calling Customer Care at the
telephone number on your ID card.
Defined Terms
The following definition of Preventive Care Medications is added to
the Outpatient Prescription Drug Rider:
Preventive Care Medications the medications that are obtained
at a Network Pharmacy with a Prescription Order or Refill from a
Physician and that are payable at 100% of the Prescription Drug
Cost (without application of any Copayment, Coinsurance, Annual
Deductible, Annual Drug Deductible or Specialty Prescription Drug
Product Annual Deductible) as required by applicable law under
any of the following:
Evidence-based items or services that have in effect a
rating of "A" or "B" in the current recommendations of the
United States Preventive Services Task Force..
With respect to infants, children and adolescents,
evidence-informed preventive care and screenings
provided for in the comprehensive guidelines supported by
the Health Resources and Services Administration.
With respect to women, such additional preventive care
and screenings as provided for in comprehensive
guidelines supported by the Health Resources and
Services Administration.
You may determine whether a drug is a Preventive Care
Medication through the internet at www.myuhc.com or by calling
Customer Care at the telephone number on your ID card.
Copayments, Deductibles and Coinsurance
The Covered Services described in this amendment are provided
at 100% when received In-Network. If Out-of-Network coverage is
available, the Covered Services described in this amendment will
be subject to the Out-of-Network Copayment or Coinsurance listed
in your Summary of Benefits for Outpatient Prescription Drugs. All
Out-of-Network Covered Services are also subject to any
applicable Plan Deductibles, benefit limits and UCR
Reimbursement as identified on your Summary of Benefits.
Miscellaneous Provisions
This Amendment forms a part of the Agreement between Oxford
Health Insurance, Inc. ("Us") and the group. Unless otherwise
agreed to in writing between Us and the group, this Amendment
becomes effective on the date the Agreement becomes effective.
This Amendment supersedes any amendment or rider providing
coverage described above previously issued by Us. In the event of
a conflict between the provisions of this Amendment and the
Certificate, the provisions of this Amendment will prevail. All other
terms and conditions of the Certificate remain in full force and
effect.

Your Oxford Coverage
for all seasons
www.oxfordhealth.com

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