Liberty Network1 Healthy NY and Healthy NY HSA Summary of Coverage and Monthly Premium Rates

Benefit
Financial Deductible Coinsurance Member out-of-pocket Preventive Care Adult preventive services Physical examination Well child visit Child immunizations (0-19 years old) Adult immunizations Outpatient Care Primary care physician office visit Specialist office visit* Surgery in physicians office** MRI, CT scan, and other radiology services** Hospital Care Physician services (non-surgical) Pre-admission testing Surgeons services Physicians anesthetic services Blood and blood products Semi-private room and board** All drugs and medications Emergency Care Ambulance service Emergency room Urgent care center Maternity Care Prenatal and postnatal care** Hospital services for mother and child** Other Coverage Diabetes supplies and education Physical therapy2 Home health care3

Healthy NY
N/A N/A N/A

Healthy NY HSA
$1,200 (single)/$2,400 (family) N/A $5,250 (single)/$10,500 ( family)

No charge No charge No charge No charge No charge

No charge No charge No charge No charge No charge

$20 copayment $20 copayment $20 copayment $20 copayment

Deductible, then $20 copayment Deductible, then $20 copayment Deductible, then $20 copayment Deductible, then $20 copayment

$20 copayment $20 copayment Lesser of $200 or 20% $20 copayment $20 copayment $500 per continuous confinement No charge

Deductible, then $20 copayment Deductible, then $20 copayment Deductible, then lesser of $200 or 20% Deductible, then $20 copayment Deductible, then $20 copayment Deductible, then $500 per continuous confinement No charge

Not covered $50 copayment; waived if admitted to hospital $20 copayment; waived if admitted to hospital $10 copayment Lesser of 20% of the cost of services or $200 $20 copayment per item or visit $20 copayment per visit $20 copayment per visit

Not covered Deductible, then $50 copayment; waived if admitted to hospital Deductible, then $20 copayment; waived if admitted to hospital $10 copayment Deductible, then lesser of 20% of the cost of services or $200 per item or visit Deductible, then $20 copayment per item or visit Deductible, then $20 copayment per item or visit Deductible, then $20 copayment per item or visit

Coverage under the Healthy New York program may be subject to pre-existing condition limitations. 1 Groups situated in Sullivan and Ulster counties must utilize the Freedom Network. 2 Up to 30 post hospital/surgical physical therapy visits per calendar year. 1 3 Up to 40 post hospital/surgical visits per calendar year.

Liberty Network1 Healthy NY and Healthy NY HSA Summary of Coverage and Monthly Premium Rates
Benefit
OPTIONAL COVERAGE
Prescription Drugs= Annual deductible $100 per member, per calendar year $10 copayment $20 copayment plus the difference in cost between the brand name drug and its generic equivalent **$1,200 (single)/$2,400 (family) shared medical and pharmacy deductible $10 copayment $20 copayment plus the difference in cost between the brand name drug and its generic equivalent

Healthy NY

Healthy NY HSA

Generic drugs Brand name drugs

Prescription drug benefits are applicable only if elected at the time of initial enrollment or renewal. ** When the deductible is exhausted, members will have a two-tier card to the shared medical/pharmacy member out-of-pocket of $5,250 (single)/$10,500 (family).

Non-covered Services Substance abuse Mental health care Long-term rehabilitation

Skilled nursing facility Chiropractic care Hospice care

Occupational therapy Durable medical equipment

Dependent Eligibility: Eligible dependents include the employees legal spouse and dependent child(ren) until the child reaches age 26. Benefits discontinue at the end of the calendar year. In accordance with Chapter 240 of the laws of 2009 eligible dependents may also include the employees dependent child(ren) through the age of 29. Benefits discontinue at the end of the calendar year. This benefit is not standard and must be chosen by you, subject to an additional payment of premium, or a young adult may choose to purchase coverage through a parents group policy. Refer to your Certificate of Coverage (COC) for full eligibility requirements. Important: * Visits to an Oxford network participating specialist require an authorized referral from your primary care physician (PCP). **These services require precertification through Oxford. You must call Oxford at 1-800 - 444-6222 at least 14 days in advance of request.

Domestic Partner
Sole Proprietors: You have the option to elect Domestic Partner coverage. Should you choose to elect this coverage please check the appropriate box in Section B of your application. Small Group Employers: Your group is eligible to elect Domestic Partner coverage. Should you choose to offer this coverage to your employees, please note your selection under question 3 in Section E of your application. Please note: The rates for Domestic Partner are the same as rates for coverage of a spouse. Please send your application along with the appropriate premium to: Oxford Health Plans, Attn: Andy Struth 14 Central Park Drive Hooksett, NH 03106
This sample Summary of Coverage is provided for informational purposes only. The applicable Summary of Benefits will be issued to eligible, enrolled members as part of the Certificate of Coverage. Coverage is subject to the terms and conditions of the certificate/contract, as required by the Healthy New York program. The exclusions listed above do not comprise a complete list of non-covered services. Please refer to your certificate/contract of coverage for more information.

Monthly Premium Rates

January - December 2011

Liberty Network Healthy New York & Healthy New York HSA Individual/Sole Proprietor and Small Group Plans
Use the table below to determine your monthly rate for the Oxford Healthy New York plan. Your rates are based on the plan you select and when your coverage goes into effect. The Oxford Liberty Network service area includes Bronx, Brooklyn, Dutchess, Manhattan, Nassau, Orange, Putnam, Queens, Rockland, Staten Island, Suffolk and Westchester counties. Groups situated in Sullivan and Ulster counties must utilize the Freedom Network.

Healthy NY
Single HNY with pharmacy HNY without pharmacy $350.17 $293.02 Parent/Child(ren) $686.62 $574.55 Husband/Wife $770.37 $644.63 Family $1,137.79 $952.09

Healthy NY - Dependent Age 29

Single HNY with pharmacy HNY without pharmacy $350.17 $293.02 Parent/Child(ren) $791.54 $662.34 Husband/Wife $770.37 $644.63 Family $1,245.99 $1,042.63

Healthy NY HSA
Single HNY HSA with pharmacy HNY HSA without pharmacy $271.65 $228.13 Parent/Child(ren) $532.64 $447.32 Husband/Wife $597.62 $501.88 Family $882.64 $741.25

Healthy NY HSA - Dependent Age 29

Single HNY HSA with pharmacy HNY HSA without pharmacy $271.65 $228.13 Parent/Child(ren) $614.03 $510.67 Husband/Wife $597.62 $501.88 Family $966.58 $811.74

These rates are only valid if Oxford receives your application on or before the 20th of the month prior to the effective date. Rates are subject to change and state approval. Oxford reserves the right to correct any typographical errors. Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc. 2010 Oxford Health Plans, Inc.
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