1st Quarter 2004 - Oxford Health Plans

1 st 

QUARTER 

Your Quarterly Update 

to the Oxford Provider 

Reference Manual 

2004 

• Oxford Policies • General Information 

• Oxford Programs • eBusiness 

• Oxford Medicare Advantage SM Program 

• Pharmacy Program • Radiology Program 

• Oxford Participating Hospitals 

O X FORD PROVIDER | PROGRAM AND 

POLICY UPDATE

1 ST QUARTER 2004 

OXFORD PROVIDER | 

Oxford Policies 

Notification of Policy Changes via the Web..........3 

Recently Approved Policies ..................................3 

Revised Policies ........................................................4 

Coverage Update for Home 

Uterine Activity Monitoring ................................10 

In-network Laboratory Update ............................10 

Reminder: Standards for Medical Records ........10 

Reimbursement Rate Adjustments Based 

on Site of Service ..................................................12 

General Information 

Oxford Opens Network to Licensed 

Professional Counselors ........................................12 

Health Plan Employer Data Information 

Set (HEDIS ® ) 2004 Request for 

Medical Records ....................................................12 

Oxford Programs 

Oxford’s Active Care Engagement SM Program......13 

eBusiness Updates 

Electronic Submission of 

Precertification Requests ..................................13 

Electronic Referral Inquiry Reminder................13 

Access Oxford’s Drug Formulary 

through ePocrates Rx ..........................................14 

PROGRAM AND 

POLICY UPDATE 

Your Quarterly Update 

to the Oxford Provider Reference Manual 

Oxford Medicare Advantage SM 

Program Updates 

2004 Prescription Drug Coverage for 

Oxford Medicare Advantage Members ..............14 

2004 Oxford Medicare Advantage 

Member Benefits ....................................................15 

Pharmacy Program Updates 

2004 Drug Formulary Update ..............................21 

Quantity Limit Updates ........................................23 

Medications Requiring Precertification ..............23 

Radiology Program Updates 

Referring Provider Update....................................24 

Precertification Update..........................................24 

Oxford Participating 

Hospitals 

Connecticut Hospitals ..........................................25 

Delaware Hospitals ................................................26 

New Jersey Hospitals ............................................26 

New York Hospitals ..............................................30 

Pennsylvania Hospitals ..........................................30 

CONTENTS 

In our ongoing efforts 

to provide the most 

prompt, correct 

information, we ask 

that you be prepared 

with your Oxford 

provider ID number 

when calling our 

Provider Services 

Department.We will 

be able to access your 

account more quickly 

and provide you with 

a more satisfactory 

experience. 

President and CEO Charles G. Berg 

Chief Medical Officer and EVP Alan M. Muney, MD, MHA 

Vice President, Marketing Chuck Green 

Director, Provider Marketing Rebecca Madsen 

Manager, Provider Marketing Maria Sommer 

Copy Editor Starlet Coleman 

Editor Stephanie Green 

The Provider Program & Policy Update is 

published exclusively for Oxford Health 

Plans by: Onward Publishing, Inc. 

10 Lewis Road, Northport, NY 11768 

Publisher Jeffrey Barasch 

Creative Director Melissa Barasch 

Editorial Director Wendy Murphy 

Art Director Bruce McGowin 

Designer Lisanne Schnell 

Project Director Tamyra Zieran 

Project Manager Bret Barasch 

Business Manager Liz Lynch 

Oxford Health Plans, Inc. and Onward Publishing, Inc. 

are not responsible for typographical errors. 

© 2004 Onward Publishing, Inc. All rights reserved.

The Oxford Provider Program and Policy Update 

(PPU), a quarterly update to your Provider 

Reference Manual, is designed to provide regular 

updates on Oxford policies and programs. 

Did you know that the PPU is available on our web 

site Simply log in to your personalized account 

page at www.oxfordhealth.com and click on 

Policies and Guidelines under the Business Center. 

Once in the Policies and Guidelines section, select 

Program and Policy Updates to read the online 

version. As always, we encourage you to e-mail your 

comments to us at publications@oxfordhealth.com, 

or write to: Oxford Health Plans, c/o Stephanie 

Green, 48 Monroe Turnpike, Trumbull, CT 06611. 

Clinical Practice 

Guidelines Availability 

As of January 1, 2003, the Clinical Practice 

Guidelines are no longer printed in the Program 

and Policy Update. If your office requires copies of 

the Clinical Practice Guidelines, simply log in to 

your personalized account at www.oxfordhealth.com. 

Click on Policies and Guidelines under the Business 

Center section and download a printable PDF. 

Simply sign up for a user name and password and 

log in to Your Account, which will allow you to 

access the following self-service transactions that 

can help streamline your administrative processes: 

• Check patient eligibility, benefits, claims, 

referrals, and precertification status 

• Submit claims, referrals and 

precertification requests 

• Submit notification of admissions (facilities only) 

• View Oxford’s Preferred Drug List 

• Search for primary care physicians, specialists, 

hospitals, health facilities, and complementary 

and alternative medicine providers 

• View radiology, physical therapy and laboratory 

program information 

• Change your address, e-mail address, password, 

and user name 

• Request self-help materials and rosters, 

download forms 

• E-mail our Provider Services Department 

If you have questions or need assistance with 

web-related inquiries, please call Oxford’s 

Team.com at 1-800-811-0881. 

You can also request a copy of the Clinical 

Practice Guidelines by calling our Provider 

Services Department at 1-800-666-1353. 

Recently updated guidelines available online include: 

Asthma 

Obstetrics 

O NEW 

Oncology 

Why Go Online 

We know how important your time can be to you. 

And we know you want convenience and options, 

so we designed our web site to give you just that. 

By logging in to www.oxfordhealth.com, you can 

conduct many transactions, when you want, 

where you want, seven days a week, 24 hours a day 

(excluding periodic downtimes for maintenance). 

Contact Information 

at a Glance 

Provider Services Department............1-800-666-1353 

Oxford Express ® ......................................1-800-666-1353 

Oxford’s Fraud Hotline ......................1-800-915-1909 

Pharmacy Customer Service ..............1-800-905-0201 

Provider eSolutions Support Team....1-800-599-4334 

2 www.oxfordhealth.com

Oxford Policies 

Issue 

Medical Policy 

M & R and MCAP criteria 

Payment Policies 

Requests for Fees 

New Medical Technology 

Explanation 

Medical policies can be requested by writing to: 

Policy Requests and Information 

Oxford Health Plans 

48 Monroe Turnpike 

Trumbull, CT 06611 

Please remember that these are proprietary services to which Oxford 

subscribes. Information on specific criteria can be requested by writing to: 

Policy Requests and Information 




Generally, our payment policies are proprietary and cannot be distributed. 

If you have questions regarding claims payment, please call our 

Provider Services Department at 1-800-666-1353. 

To request information regarding fees, please call our Provider Services 

Department at 1-800-666-1353. 

Requests for review of new medical technology can be made by writing to: 

New Medical Technology 




Notification of Policy Changes via the Web 

Beginning December 1, 2003, notification of new 

and revised clinical and/or payment policies are 

being communicated online through the provider 

Policy Update section of www.oxfordhealth.com 

on the first business day of every month. The 

web site postings will serve as the 30-day prior 

notification for all new or revised policies. 

The policy section of this printed Provider Program 

and Policy Update (PPU) will continue to document 

new or revised policies. However, since the PPU is 

published quarterly, the policy section may reflect 

policies already implemented and communicated 

through the monthly web site notification. To ensure 

you are aware of new or revised policies, please log 

in to www.oxfordhealth.com to check the Policy 

Update section. 

Recently Approved Policies 

The appearance of an item or procedure on this 

list indicates only that Oxford has recently adopted 

a policy; it does not imply that Oxford provides 

coverage for the item or procedure listed. 

• Forteo ® (teriparatide) 

• Provigil ® (modafinil) 

• Strattera (atomoxetine) 

• Unlisted CPT Codes Requiring Medical 

Director Review 

• Intranasal Influenza Vaccine for 

Commercial Plans 

• Intranasal Influenza Vaccine for 

Oxford Medicare Advantage SM Plans 

• Providers Requesting Retainer for Services 

www.oxfordhealth.com 3

Recently Approved Policies (continued) 

• Credentialing Criteria for Physician Assistants 

• Notification of Oxford Medicare Advantage SM 

Plan Physicians upon Termination 

• Xolair ® (omalizumab) for Commercial Plans 

• Xolair ® (omalizumab) for Oxford Medicare 

Advantage Plans 

• Credentialing for Licensed Professional 

Counselors 

• Vasclip ® 

Revised Policies 

The following policies underwent their scheduled 

review; no changes were made. 

• Dialysis Services for Oxford Medicare 


• Weight Loss Medications (Anorexiants) 

• Extracorpeal Shock Wave Therapy 

• Liver Dialysis 

• Rhinoplasty 

• Nasal and Sinus Surgery 

Name of Policy 

Diabetes Supplies (including blood 

glucose monitors, insulin and syringes) 

for Oxford Medicare Advantage Plans 

Expedited 72-Hour Reviews 

(Organizational Determinations) for 

Oxford Medicare Advantage Plans 

Balance Billing for Oxford Medicare 


Updates/Changes 

• Replaced HCPCS code E0609 with E2100 and E2101 

• Added HCPCS codes E0620, A4210 and A4255, all 

of which are not covered by Centers for Medicare & 

Medicaid Services (CMS) or Oxford Health Plans 

Added additional details regarding Oxford’s required actions 

when handling an expedited review, including when a 

request for an expedited review is denied or approved 

• Added definitions for covered services, participating and 

non-participating Oxford Medicare Advantage provider 

• Added information detailing when participating providers 

may not bill Members 

Colorectal Cancer Screening for Oxford 

Medicare Advantage Plans 

• Added HCPCS code G0122 as not covered by Medicare 

• Added information regarding coverage of HCPCS code 

G0121, as recommended by CMS: 

A screening colonoscopy is covered once every 10 years 

(at least 119 months have passed since the last screening 

colonoscopy) for those who do not meet the criteria listed 

in the policy for determining high-risk for developing 

colorectal cancer 

If the Member would otherwise qualify for a screening 

colonoscopy based on his or her not being high-risk 

and the recommended frequency above, but he or 

she has had a covered screening sigmoidoscopy (G0104), 

then he or she may have a covered screening colonoscopy 

only after at least 47 months have passed since the 

covered sigmoidoscopy 


Revised Policies (continued) 


Post-Stabilization Services for Oxford 

Medicare Advantage SM Plans 

Dialysis Services for Commercial Plans 

In-Vitro Chemosensitivity Assays for 

Predicting Tumor Responses to 

Chemotherapy in Ovarian Cancer 


Updated description of post-stabilization services 

Due to insufficient clinical evidence to support medical 

efficacy, short-run or short-daily dialysis is not covered 

by Oxford 

• Policy remains, no coverage is provided 

• Removed unlisted CPT code 88199 

• Added the following: 

1. CPT code 87230 

2. ICD-9 codes related to ovarian cancer 

Surgical and Non-Surgical Treatment of 

Temporomandibular Joint (TMJ) Disorders 

Lupron ® (leuprolide acetate) 

Bextra ® (valdecoxib) 

The following procedures are not covered for the diagnosis 

or treatment of TMJ disorders: 

1. Muscle testing or range of motion measurements 

(included as part of TMJ evaluation) 

2. Electromyography (EMG) 

3. Neuromuscular junction testing or somatosensory testing 

4. Sonogram (ultrasonic doppler auscultation) 

5. Computerized mandibular scan 

6. Kinesiology 

7. Jaw tracking 

8. Thermography 

9. Standard dental radiographs 

10. Arthroscopy of the TMJ for diagnostic purposes only 

• Added FDA-approved indications and usage to 

Description of Service and Policy and Rationale 

• Added information regarding coverage for use in the 

treatment of infertility 

• Added FDA-approved indications, usage and precautions 

to Description of Service and Policy and Rationale 

• Added information on the prevention and treatment 

of cancer and Alzheimer’s disease to Description of 

Service, and Policy and Rationale 

• Added information regarding intolerance to two or more 

prescription NSAIDs with a diagnosis of rheumatoid 

arthritis, osteoarthritis or dysmenorrhea to coverage 

criteria in Treatment/Application Guidelines 




Kineret ® (anakinra) 

Dermatological Procedures Requiring 

Precertification for Commercial Plans 

Notice of Discharge and Medicare 

Appeal Rights (NODMAR) for 

Oxford Medicare Advantage SM Plans 

Providers Caring for Themselves 

or Relatives 

Epidurolysis (RACZ Catheterization) 

and Epidurography 

Drug Coverage Guidelines for 



Added FDA-approved indications, usage and precautions 

to Description of Service and Policy and Rationale 

• Only CPT code 17106 requires precertification with Medical 

Director review for port wine stains, birthmarks and strawberry 

nevus (ICD-9 code 757.32), and hemangioma (ICD-9 code 228.01) 

• CPT codes 17107 and 17108 require precertification with 

Medical Director review regardless of setting 

• Removed non-covered CPT codes from the policy and 

added a link to the Reconstructive and Corrective Surgery, 

and Cosmetic Surgery policies 

As of May 5, 2003, CMS only requires a NODMAR for 

disputed discharges, not all discharges 

Neither Oxford Health Plans nor CMS pays for services usually 

covered under Medicare and/or Oxford if the charges for 

those services are imposed/rendered by a provider who has 

an excluded relationship to the Member. An excluded 

relationship is one where the billing provider is: 

• An immediate relative of the Oxford Member, or 

• A member of the Oxford Member’s household*, or 

• An enrolled Oxford Member caring for himself/herself 

*Any references to member of the household are strictly related to Oxford Medicare Advantage 

plans, including Medicare Group Accounts (MGAs). 

Added epidurography (CPT code 72275) to non-covered services 

• To request coverage of medications that may require 

precertification, have a quantity limit in place or that 

do not appear in the policy, or to request coverage of 

medications that are excluded from coverage under 

the Member’s pharmacy benefit, providers can fax a 

letter of medical necessity to Oxford at 1-203-452-4810 

Please note: Inpatient medications or medications obtained from 

a physician do not count towards the pharmacy benefit. In these 

circumstances, medications may be available under the Member’s 

medical benefit. Specific policy guidelines may apply. 

• Added the following: Aranesp, Arixtra, Calderol, Carnitor, Cipro 

XR, contraceptives, Delatestryl, Edex, Famvir, fluoride vitamins, 

folic acid, Forteo, Frova, Fuzeon, Hytakerol, infertility drugs, 

Kytril, Lotronex, Migranal, Muse, Neulasta, Potava, prenatal 

vitamins, Provigil, Singulair, Sporanox, Strattera, Striant, Testim, 

Testred, Valtrex, weight-loss medications, Zelnorm, and Zithromax 




Essure Permanent Tubal 

Sterilization System 

Zevalin (ibritumomab tiuxetan) 

Anesthesia Services for Dental/Oral 

Surgical Procedures 


At the time precertification is obtained for Essure in an 

outpatient setting (precertification is not required for in-office 

treatment) (CPT code 58615), precertification should also be 

obtained for the three-month follow-up study (CPT code 58340) 


1. ICD-9 codes 

2. HCPCS codes A9522, A9523, G0273, and G0274 

3. Multiple course treatment 

• Changed as follows per Connecticut P.A. No. 03-37, an act 

requiring health insurance coverage for craniofacial disorders: 

• Removed age limit from Connecticut 

coverage requirements 

• Added the following to Connecticut coverage requirements: 

Medically necessary orthodontic processes and appliances 

for the treatment of craniofacial disorders for individuals 

eighteen years of age or younger 

• For New York plans: 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 

Cognitive and Neuropsychological 

Testing and Rehabilitation for 


• Opened Neuropsychological Rehabilitation/Cognitive 

Rehabilitation (CPT codes 97532 and 97533) to 

New Jersey public sector (formerly New Jersey School Board) 

• Precertification is not required for New Jersey public 

sector plans for all cognitive and neuropsychological testing 

Biofeedback for Commercial Plans 

• Group biofeedback education training (i.e., more than 

one patient involved with a practitioner in training) is 

not covered 

• Added recommended guideline: 

Usually, biofeedback sessions are limited to six (6) treatments 

per six (6) months, per condition 




Biofeedback for Oxford Medicare 

Advantage SM Plans 


• Group biofeedback education training (i.e., more than 

one patient involved with a practitioner in training) 

is not covered 

• Added recommended guideline: 

Usually, biofeedback sessions are limited to six (6) 

treatments per six (6) months, per condition 

• Changed ICD-9 codes from 788.30-788.39 to 788.30-788.33 

• Biofeedback therapy is only covered when all of the 

following criteria exist: 

1. The patient is motivated to actively participate in 

the treatment plan, including being responsive to 

the care plan requirements (i.e., practice and follow 

through at home) 

2. The patient is capable of participating in the treatment 

plan (physically as well as mentally) 

3. The patient’s condition can be appropriately treated 

with biofeedback (e.g., pathology does not exist 

preventing success of treatment) 

• Biofeedback therapy is covered for the treatment of stress 

and/or urge incontinence in cognitively intact patients 

who have failed a documented trial of pelvic muscle 

exercise (PME) training; a failed trial of PME training 

is defined as no clinically significant improvement in 

urinary incontinence after completing four (4) weeks 

of an ordered plan of pelvic muscle exercises to increase 

periurethral muscle strength 

Prosthetics 


1. Ocular prosthesis V2630-V2632 

2. Coverage is for one (1) permanent external prosthetic 

device, per lifetime, per body part, to replace a natural 

part of a covered person’s body, subject to replacement 

and repair guidelines 

3. Periodically, new technologies produce new prostheses; 

Oxford does not cover new technology computerized 

limb prosthetics due to the lack of published medical 

evidence in peer-reviewed literature showing significant 

advantages over well-fitted and trained standard 

prostheses in helping a patient accomplish the 

activities of daily living 




Prophylactic Mastectomy 


Added the following: 

• Women with a family history of the disease may choose 

to undergo genetic testing for BRCA1, BRCA2, BRCA3, and 

BRCA4 mutations 

Chelation Therapy 

Computerized Limb Prosthesis 

Added the following oral agents: Succimer (DMSA), 

D-Penicillinamine, Trientine hydrochloride (Syprine) 

• Policy remains, no coverage is provided 

• Added HCPCS codes for Upper Limb — L6646, L6648, 

L6882, L6025, L6920-L7274, L7360-L7499 

Spinal Axial Decompression Therapies: 

Computerized Axial Decompression, 

Vertebral Axial Decompression (VAX-D), 

Decompression Reduction Stabilization 

(DRS) System, Internal Disc Decompression 

(IDD) Therapy 

Preventive Treatment for Respiratory 

Syncytial Virus including Synagis/RespiGam 

• No longer referred to as the VAX-D policy 

• Due to insufficient clinical evidence to support medical 

effectiveness, the following spinal axial decompression 

therapies are not covered by Oxford: computerized axial 

decompression, VAX-D (vertebral axial decompression), 

decompression reduction stabilization (DRS) system, 

and internal disc decompression (IDD) therapy 

• Changed total dosage from six (6) doses to up to 

six (6) doses 

• Changed time frame given for from November through 

April to October through April 

• Expanded section on use for immunocompromised children 

Gastric Surgery for Severe Obesity 


• Medical Director review is required for all lap band 

requests, unless the body mass index (BMI) is greater 

than or equal to 40 and the surgeon is certified by 

Bio-Enterics to perform the procedure 

• Added CPT code 44238 

• Removed hypertension as a co-morbid condition, replaced 

with pulmonary hypertension of obesity 

Immunizations/Vaccinations for 


• Identified specific travel vaccines as not covered 

• Added FluMist for healthy children and adults age five 

to 49 (precertification required) 

• CPT code 90680 (Rotavirus) is no longer available on 

the market and, therefore, is not covered 




Immunizations/Vaccinations for Oxford 

Medicare Advantage SM Plans 


• Removed the following HCPCS codes: Q0321, Q0322 

and Q0323 

• Due to a reconsideration decision from CMS, the following 

codes are eligible for reimbursement: 90723, 90740, 90743, 

90744, 90746, 90747, and 90748 


• Specific travel vaccines identified as not covered 

• Intranasal influenza vaccine verbiage 

• CPT code 90680 (Rotavirus) is no longer available on 

the market and, therefore, is not covered 

Coverage Update for Home Uterine 

Activity Monitoring 

Effective February 1, 2004, Oxford will no longer 

provide coverage for home uterine activity 

monitoring (HUAM). This decision is consistent 

with the positions of professional societies and 

government policy agencies. The American College 

of Obstetricians and Gynecologists has stated: 

Although the U.S. Food and Drug 

Administration has approved a HUAM 

device for women with a prior preterm birth, 

there is no demonstrated role for HUAM in 

the prevention of preterm birth. Data is 

insufficient to support a benefit from HUAM 

in preventing preterm birth; therefore, this 

system of care is not recommended. 

A review of our claims data indicates that only a 

small minority of Oxford’s obstetrical care providers 

have been ordering HUAM. Members currently 

using HUAM will continue to be covered for use 

through the term of their existing pregnancies. 

In-network Laboratory Update 

Oxford is pleased to announce that the Mansfield 

Connecticut PSC has been added to our outpatient 

lab network, effective October 27, 2003. You can 

call Mansfield Connecticut PSC at 1-888-868-2191. 

Reminder: Standards for Medical Records 

Medical records should include the following 

documentation, as well as any other information 

deemed appropriate or required by 

applicable standards: 


• Patient name on each page 

• Address, phone number, Social Security number, 

or other identifiers 

• Name of next of kin 

• Date of visit 

• Signature of person making the entry 

Immunization Record 

• For all children of school age 

• Record of Tetanus-diphtheria (Td) booster, 

flu vaccine and pneumococcal vaccine for 

applicable adults 


Treatment Plan 

• Documentation to support that the treatment 

plan is appropriately carried out through 

the following: 

• Diagnostic testing 

• Use of medication 

• Referrals to specialists 

• Surgical interventions 

Medical History 

• Documentation of past medical, surgical, 

family, and social history 

• Birth history should be noted for children 

under age 10 

• Notation of the chief complaint or reason for 

each visit with history of the present illness 

Preventive Screening 

• Evidence of appropriate preventive screening, 

based on clinical guidelines, by sex and age 

Continuity of Care 

• Evidence of continuity of care documented 

to reflect the following: 

• Problems of previous visits are addressed 

• The physician (reports dated and initialized) 

showing review results of diagnostic testing 

and abnormal results are noted and followed 

up appropriately 

• Consultation reports or notes are made by 

the physician reflecting the results of specialist 

referrals with evidence that recommendations 

are followed through 

• Recent hospitalizations, ER visits, ambulatory 

surgeries, etc., are recorded and follow-up is 

completed as needed 

• A complete problem list and medication list is 

maintained for patients with multiple and/or 

chronic problems 

• Documentation of communication via 

behavioral health provider communications 

exists for those Members in ongoing treatment 

Allergies 

• Notation of allergies or lack of allergies on a 

face sheet or initial visit sheet 

• Allergies to medications or any other severe, 

potentially life-threatening allergic reactions 

that should be flagged (e.g., severe food allergies, 

bee stings, contrast dye) 

Physical Exam Information 

• Documentation of a pertinent physical exam 

that includes: 

• Height and weight by the third visit, followed 

up as applicable for pediatrics, obesity, etc. 

• Record of vital signs, including baseline 

heart rate, respirations and temperature, 

as applicable, for any complaint indicating 

possible infection 

• Blood pressure, recorded as appropriate for 

age and history 

• Complete review of systems for a complete 

physical exam and/or review of pertinent 

systems for any acute care or follow-up visits 

• Notation and revision of a working diagnosis 

• Written plan that is consistent with the diagnosis 

Family Communications 

• Evidence of communication with the 

patient/family about the following: 

• Patient/family notification of abnormal 

test results 

• Need for return visit 

• Need for special diet, therapeutic 

exercise, restriction of activity, or any 

other special instruction 

• Signed consent form for all invasive procedures 

• Signed release of confidential information 

as necessary 


Reimbursement Rate Adjustments 

Based on Site of Service 

At Oxford, we value the care you provide to 

Oxford Members and appreciate your cooperation 

as we work toward a common goal — to offer 

Members access to medically appropriate, costeffective 

healthcare. One way to manage costs 

is to encourage the delivery of services in the 

most effective settings when possible. In an effort 

to achieve this goal and to better align our 

payment policies with industry standards we 

have been evaluating our reimbursement rates 

based on the site of service. 

While we will continue to provide you with choice 

of where you deliver services, please note that 

in the near future, certain procedures performed 

in an in-office setting will generally be reimbursed 

at higher rates than procedures performed in an 

out-of-office setting. More information regarding 

these rate adjustments will be posted on our web 

site over the next few months. You can check by 

logging into www.oxfordhealth.com and visiting 

the Business Center. Once in the Business Center, 

click on Policies and Guidelines, then click on 

the Reimbursement Rate Adjustment link. We 

appreciate your continued commitment to 

providing quality healthcare services to Oxford 

Members, as well as your continued participation 

in Oxford’s network. 

If you have any questions concerning Oxford’s 

payment policies, please call Provider Services 

at 1-800-666-1353. 


Oxford Opens Network to 

Licensed Professional Counselors 

Oxford is now accepting applications from 

licensed professional counselors (LPC) for 

participation in our provider network. LPCs 

who wish to become a participating provider 

must meet the following criteria: 

• Current, valid state license 

• Masters degree in a behavioral health discipline 

from an accredited college or university 

• Malpractice insurance in the amounts of 

$1,000,000 per occurrence, $3,000,000 in 

the aggregate 

• Documentation of a formal arrangement for 

psychiatric medication consultation 

• If an LPC states he or she works with children 

and/or adolescents, he or she must provide 

documentation of training and at least 200 hours 

of supervised clinical work with children and 

adolescents and their families 

• History of professional liability claims review 

• Medicaid/Medicare sanctions review 

• A work history with explanations of any gaps 

from completion of school/training program 

to date of current practice 

• W-9 Form 

To request an application for participation, 

licensed professional counselors should 

call Oxford’s Provider Services Department 

at 1-800-666-1353. 

Health Plan Employer Data 

Information Set (HEDIS ® ) 2004 

Request for Medical Records 

Each year Oxford collects data from a randomly 

selected sample of its Members medical records 

for HEDIS. HEDIS is mandated by the New York 

Department of Health, New Jersey Department 

of Health and Senior Services, Connecticut 

Department of Health, and the Centers for 

Medicare & Medicaid Services (CMS). The 

HEDIS medical record study measures Oxford’s 

participating physicians’ adherence to nationally 

accepted clinical practice guidelines. 

We encourage you to alert your office staff that 

requests for information will begin in March. We 

recognize the additional time and work HEDIS 

places on your busy practice and we thank you for 

your cooperation in years past and look forward 

to a successful HEDIS data collection in 2004. 


Oxford Programs 

Oxford’s Active Care Engagement SM 

Program 

Oxford’s new Active Care Engagement (ACE) 

program is a comprehensive, health management 

program for high-risk Members with heart failure, 

coronary artery disease or diabetes. The program 

is designed to help Members manage their chronic 

condition, which results in improved health and 

quality of life. Member support includes regular 

intervention by telephone that focuses on lifestyle 

modification, education of the disease process, 

symptom management, and medication adherence. 

Additionally, ACE assists physicians in their 

successful management of the chronically ill 

Member. Physicians with Members participating 

in the program receive disease-specific guidelines 

for care, patient-specific data reports and a variety 

of educational and support materials geared toward 

improving adherence to nationally recognized care 

guidelines for cardiac and diabetes conditions. 

If you have any questions about the ACE program, 

please call 1-877-759-3059. 

eBusiness Updates 

Electronic Submission of 

Precertification Requests 

The ability to submit precertification requests 

electronically is just another example of how 

Oxford is striving to help make your office 

administration tasks easier. We understand 

that you may have difficulty submitting electronic 

precertification requests as a result of the changes 

that were put in place to comply with the Health 

Insurance Portability and Accountability Act 

(HIPAA) standards. 

We would like to provide you with a few helpful 

tips to guide you through the process of submitting 

your precertification requests electronically. 

To receive appropriate auto approvals and expedite 

your request in a timely manner, the following 

information must be included on every request: 

• Type of Service 

• Place of Service: The most commonly used 

codes are: 

11 Office 

21 Inpatient Hospital 

22 Outpatient Hospital 

24 Ambulatory Surgical Center 

31 Skilled Nursing Facility 

• CPT Code 

• Oxford Servicing Provider ID 

• Facility/Secondary Service Providers Information: 

If you are submitting a precertification request 

for an inpatient or outpatient procedure, you 

will need to include the facility where the services 

will be rendered and any secondary service 

providers (e.g., co-surgeon, assistant surgeon) 

If you would like additional assistance submitting 

your precertification requests electronically, 

please contact Oxford’s Provider eSolutions 

Support Team at 1-800-599-4334. 

Electronic Referral Inquiry Reminder 

To help streamline your administrative processes, 

Oxford provides access to, and strongly encourages 

you to utilize, the various electronic mediums for 

your referral inquiries. The following methods are 

available to you: 

• Oxford Express ® (1-800-666-1353) 

• www.oxfordhealth.com 

• WebMD point-of-service terminal 

• WebMD office product 

• ProxyMed (formerly MedUnite) 


You can use one of these mediums to obtain 

the following information about your referrals: 

• Reference number 

• Status of the referral 

• Referring provider 

• Referred-to provider 

• Authorized number of visits 

• Referral effective date 

Access Oxford’s Drug Formulary 

through ePocrates Rx 

Did you know that as of July 2003, Oxford’s 

formulary became available via ePocrates Rx, 

a free clinical drug reference guide with formulary 

information that can be viewed on your personal 

digital assistant (PDA), as well as your desktop 

The ePocrates clinical drug database includes 

information about dosing, contraindications, drug 

interactions, and adverse reactions. The formulary 

feature displays formulary status and tier and lists 

therapeutic alternatives. It also shows users whether 

a drug requires precertification or has quantity 

limits. Requirements vary depending on plan 

design. Oxford has supplied ePocrates with our 

standard three-tier prescription drug formulary. 

ePocrates will update Oxford’s formulary on a 

quarterly basis to coincide with any changes made 

by Oxford’s Pharmacy and Therapeutics Committee. 

There is no charge to download Oxford’s formulary. 

For more information on how to download 

Oxford’s formulary through ePocrates, log in 

to www.epocrates.com and follow the directions 

on how to load the product and the formulary, 

or look for the ePocrates link on your provider 

home page on www.oxfordhealth.com. You can 

also contact your Provider Relations Representative 

for more information. 

Oxford Medicare 

Advantage SM 

Program 

Updates 

2004 Prescription Drug Coverage for 

Oxford Medicare Advantage Members 

Please note the addition of a new exception policy 

that applies to Members who may be affected by a 

change in the tier classification or coverage for a 

drug. The policy applies when a change becomes 

effective during the calendar year; such changes 

include those that may occur as a result of a decision 

by Oxford’s Pharmacy and Therapeutics Committee. 

Drug Formulary Policy 

Oxford shall retain the right to make changes to 

the drug formulary at any time during the calendar 

year, such as adding or removing drugs from the 

formulary and moving drugs to a different tier 

level. In the event a drug is removed from the 

formulary during the calendar year and is no 

longer covered under the Member’s pharmacy 

plan, and the Member was receiving coverage from 

Oxford Medicare Advantage (OMA) for the drug 

on the date of the change, the Member’s physician 

may contact Oxford so we may determine whether 

the drug should continue to be covered for the 

Member either for the remainder of the calendar 

year, or until he or she is no longer an OMA 

Member, or until the drug is no longer medically 

necessary, whichever comes first. 

Under this “exception policy,” the Member’s 

physician may continue to prescribe the drug for 

the remainder of the calendar year, and the Member 

may receive coverage under the same terms as he or 

she did prior to the change. Those terms include the 

following: the drug must continue to be medically 

necessary for the Member’s condition and treatment; 

precertification must be obtained if it is applicable to 

the drug; the Member’s annual maximum pharmacy 

benefit must not have been exhausted; and the 

Member must continue to be an OMA Member. 

Please note: This “exception policy” does not apply to 

changes in precertification requirements, which may be 

added or removed during the calendar year with prior notice. 


2004 Oxford Medicare Advantage SM 

(OMA) Member Benefits 

Effective January 1, 2004, Oxford Medicare 

Advantage continues to be available in the 

following areas: 

New York: 

New Jersey: 

Connecticut: 

Bronx, Kings (Brooklyn), New York 

(Manhattan), Queens, and 

Richmond (Staten Island) counties 

Hudson County 

New Haven County 

2004 New York Oxford Medicare 


Oxford Health Plans will continue to offer 

Medicare beneficiaries four Oxford Medicare 

Advantage plans to choose from in 2004. For 

your quick reference, we have provided an 

overview of the four Oxford Medicare Advantage 

plans being offered in New York in 2004. 


Signature 

The 2004 Oxford Medicare Advantage Signature plan is available in Bronx, Kings (Brooklyn), New York 

(Manhattan), Queens, and Richmond (Staten Island) counties in New York. The following chart compares 

the 2004 OMA Signature benefits to the plan benefits offered in 2003. 

Benefit 2003 2004 

Monthly plan premium $0 $0 (no change from 2003) 

Primary care physician copayment $15 $15 (no change from 2003) 

Specialist copayment $25 $25 (no change from 2003) 

Generic drug annual limit Unlimited Unlimited (no change from 2003) 

Generic drug cost share The greater of (i) $15 and The greater of (i) $15 and (ii) 50% 

(ii) 50% of the total cost 1 of the total cost 1 of the covered 

of the covered drug 2 drug2 (no change from 2003) 

Combined preferred and non-preferred $500 $1100* 

brand drug annual limit 

Preferred brand drug cost share The greater of (i) $25 and The greater of (i) $25 and (ii) 50% 


of the covered drug2 drug2 (no change from 2003) 

Non-preferred brand drug cost share The greater of (i) $50 and The greater of (i) $50 and (ii) 50% 


of the covered drug 2 drug2 (no change from 2003) 

Inpatient hospital facility copayment $500 per benefit period3 $80 per day; not to exceed $640 

per hospital stay* 

Inpatient hospital surgery copayment $150 $150 (no change from 2003) 

Ambulatory surgery facility copayment $200 $250 

Ambulatory surgery physician copayment $75 $100 

Radiology services No charge 20% coinsurance 


Oxford Medicare Advantage Signature (continued) 


Ambulance services No charge 20% coinsurance 

Skilled nursing facility services No charge $0 for days 1-10 

$75 for days 11-100 

Limited to 100 days per 

benefit period 3 

* Pending Federal approval. 

1 The total cost of the covered drug will reflect Oxford’s discounted rates, plus a prescription dispensing fee, minus an average per-drug forecast of the 

pharmacy rebates Oxford expects to receive for formulary drugs. 

2 If the total cost of the covered drug is less than $15 for generic drugs, $25 for preferred brand drugs or $50 for non-preferred brand drugs, the Member 

pays the total cost of the covered drug. 

3 A benefit period begins the first day the Member is admitted to a hospital or skilled nursing facility.The benefit period ends when the Member has not 

received hospital or skilled nursing facility care for 60 consecutive days. If the Member is admitted to a hospital after one benefit period has ended, a new 

benefit period begins.The Member must pay the inpatient hospital deductible for each new benefit period.There is no limit on the number of benefit 

periods a Member can have. 


Balance 

Oxford introduced this plan in January 2003 to provide an option for those who want to have a general idea 

of what their annual healthcare costs will be. This plan replaces the various copayments for inpatient and 

outpatient hospitalization found in OMA Signature with one annual deductible of $1,500** for these services. 

Effective March 1, 2004, Members will no longer require a PCP referral when seeing a specialist.* The 2004 

Oxford Medicare Advantage Balance plan is available in Kings (Brooklyn), New York (Manhattan), Queens, 

and Richmond (Staten Island) counties in New York. (The OMA Balance plan is not offered in Bronx 

County). The following chart compares the 2004 OMA Balance benefits to the plan benefits offered in 2003. 






Generic drug cost share The greater of (i) $15 and The greater of (i) $15 and 

(ii) 50% of the total cost 1 (ii) 50% of the total cost1 

of the covered drug2 of the covered drug2 

(no change from 2003) 

Combined preferred and non-preferred $500 $1200* 


Preferred brand drug cost share The greater of (i) $25 and The greater of (i) $25 and 

(ii) 50% of the total cost 1 (ii) 50% of the total cost1 

of the covered drug 2 of the covered drug 2 



Oxford Medicare Advantage Balance (continued) 


Non-preferred brand drug cost share The greater of (i) $50 and The greater of (i) $50 and 

(ii) 50% of the total cost 1 (ii)50% of the total cost 1 



Inpatient hospital facility copayment $0** $0** (no change from 2003) 

Inpatient hospital surgery copayment $0** $0** (no change from 2003) 

Ambulatory surgery facility copayment $0** $0** (no change from 2003) 

Ambulatory surgery physician copayment $0** $0** (no change from 2003) 


** Oxford will cover the first $500 of the costs associated with certain services such as inpatient and outpatient hospital care and then the Member is responsible 

for paying the next $1500. Copayments will apply toward the initial $500 of services provided as outlined above; however, there are no additional copayments 

for services applied toward the $1500 deductible. For those services, the Member will not be responsible for additional costs beyond the $1,500 deductible. 

1 The total cost of the covered drug will reflect Oxford’s discounted rates, plus a prescription dispensing fee, minus an average per-drug forecast of the 

pharmacy rebates Oxford expects to receive for formulary drugs. 

2 If the total cost of the covered drug is less than $15 for generic drugs, $25 for preferred brand drugs or $50 for non-preferred brand drugs, the 

Member pays the total cost of the covered drug. 

The $1,500 deductible does not apply to: 

• Physician office visits 

• Wellness visits (preventive care) 

• Urgent care 

• Emergency room 

• Immunizations 

• Allergy testing and treatment 

• Occupational therapy 

• Speech therapy 


Essential 

• Physical therapy 

• Chiropractic services 

• Radiology services 

• In-office surgery 

• Additional Oxford benefits and services (hearing, 

vision, podiatry visits, nutrition visits, exercise 

and fitness classes, worldwide emergency care, 

non-Medicare covered drugs, and dental services) 

Please note: Copayments may apply to some of the 

benefits listed above. 

Oxford introduced this plan in August 2001 to meet the needs of those who do not want to pay a copayment 

for services such as inpatient and outpatient hospital care, and those who may not require brand name 

prescription drug coverage or have brand name prescription drug coverage through other sources such 

as the Elderly Pharmacy Insurance Program (EPIC). The 2004 OMA Essential plan is available in Bronx, 

Kings (Brooklyn), New York (Manhattan), Queens, and Richmond (Staten Island) counties in New York. 

The following chart compares the 2004 OMA Essential benefits to the plan benefits offered in 2003. 





Oxford Medicare Advantage Essential (continued) 




Generic drug cost share The greater of (i) $15 and $15* , ** 

(ii) 50% of the total cost 1 

of the covered drug 2 

Combined preferred and non-preferred None None (no change from 2003) 


Inpatient hospital facility copayment $0 $0 (no change from 2003) 


Ambulatory surgery facility copayment $0 $0 (no change from 2003) 

Ambulatory surgery physician copayment $0 $0 (no change from 2003) 


** If the total cost of the covered drug is less than $15 for generic drugs, the Member pays the total cost of the covered drug. 


Plus 

The Oxford Medicare Advantage Plus plan provides Members with the freedom to see providers outside the 

Oxford network and still receive coverage. The 2004 OMA Plus plan is available in Bronx, Kings (Brooklyn), 

New York (Manhattan), Queens, and Richmond (Staten Island) counties in New York. The following chart 

compares the 2004 OMA Plus benefits to the plan benefits offered in 2003. 


Monthly plan premium $125 $170 




Generic drug cost share The greater of (i) $15 and The greater of (i) $15 and 

(ii) 50% of the total cost 1 (ii) 50% of the total cost 1 

of the covered drug2 of the covered drug.2 


Combined preferred and non- $750 $500 

preferred drug annual limit 

Preferred brand drug cost share The greater of (i) $25 and The greater of (i) $25 and 






Plus (continued) 


Non-preferred brand drug cost share The greater of (i) $50 and The greater of (i) $50 and 




Inpatient hospital facility copayment $500 per benefit period 3 $80 per day; not to exceed 

$640 per hospital stay* 







$75 for days 11-100 

Limited to 100 days per benefit period 


1 The total cost of the covered drug will reflect Oxford’s discounted rates, plus a prescription dispensing fee, minus an average per-drug forecast of the pharmacy 

rebates Oxford expects to receive for formulary drugs. 

2 If the total cost of the covered drug is less than $15 for generic drugs, $25 for preferred brand drugs or $50 for non-preferred brand drugs, the Member pays 

the total cost of the covered drug. 

3 A benefit period begins the first day the Member is admitted to a hospital or skilled nursing facility.The benefit period ends when the Member has not received 

hospital or skilled nursing facility care for 60 consecutive days. If the Member is admitted to a hospital after one benefit period has ended, a new benefit period 

begins.The Member must pay the inpatient hospital deductible for each new benefit period.There is no limit on the number of benefit periods a Member can have. 

The following chart compares the 2004 OMA Plus out-of-network coverage to the out-of-network coverage 

offered in 2003. This benefit applies to care provided by non-participating providers. 

Please note: Medically necessary, worldwide emergency care does not apply toward the out-of-network benefit. 

Out-of-network Benefit 2003 2004 

Out-of-network deductible $200 per calendar year $200 per calendar year 


Out-of-network coinsurance 15% — once the deductible is met 15% — once the deductible is met 


Out-of-network maximum $500,000 per calendar year $500,000 per calendar year 


Referrals Not required for care provided by Not required for care provided 

non-participating providers 

by non-participating providers 


Precertification Member must call Oxford for Member must call Oxford for 

authorization of all out-of-network authorization of all out-of-network 

care requiring precertification care requiring precertification 



Additional Benefits Offered by New York OMA Plans 

Benefit 

Standard vision 

Enhanced vision 

Benefit Description 

$50 reimbursement for an eye exam provided by any optometrist or 

ophthalmologist once every 12 months and $70 reimbursement for eyeglasses 

or contact lenses once every 24 months. PCP referral is not required. 

Services must be provided by a Davis Vision provider. One (1) vision exam once 

every 12 months at no charge and one (1) set of eyeglasses or contact lenses once 

every 24 months at no charge. PCP referral is required (not required for OMA 

Balance plan Members). 

Standard hearing One (1) hearing exam provided by an Oxford affiliated audiologist once every 12 

months; specialist copayment applies. PCP referral is required (not required for 

OMA Balance plan Members). $300 reimbursement for a hearing aid purchased 

from any supplier once every 36 months. 

Enhanced hearing 

Podiatry 

Dental care 

Nutrition 

Fitness 

Services must be provided at a Hear x Center. One (1) hearing exam every 

12 months at no charge and a $700 discount toward a hearing aid once every 

36 months. PCP referral is not required. 

Four (4) (one per quarter) routine visits (cutting or scraping of nails) 

at no charge. PCP referral is not required. 

Preventive and diagnostic dental care provided by an Oxford participating primary 

care dentist at no charge. Basic and major dental services provided by an Oxford 

participating dental provider are provided at a discounted rate negotiated by Oxford. 

Preventive nutrition consultation every 12 months at no charge. PCP referral 

not required. If necessary, one (1) intervention and one (1) follow-up visit every 

12 months. A specialist copayment applies per visit. PCP referral is required (not 

required for OMA Balance plan Members). 

Basic gym membership including all amenities at participating fitness facilities 

at no charge. PCP authorization may be required. 

2004 New Jersey and Connecticut Oxford Medicare Advantage SM Plans 

Medicare beneficiaries who reside in Hudson County, New Jersey and New Haven County, Connecticut are 

offered identical plans. The chart below compares the 2004 OMA benefits available in Hudson County, 

New Jersey and New Haven County, Connecticut to the plan benefits offered in 2003. 





Prescription drug benefit None None (no change from 2003) 


2004 New Jersey and Connecticut Oxford Medicare Advantage SM Plans (continued) 


Inpatient hospital facility copayment $810 per benefit period 1 $840 per benefit period 1 

Inpatient hospital surgery copayment $200 $250 






$75 for days 11-100 

Limited to 100 days per 

benefit period 

1 A benefit period begins the first day the Member is admitted to a hospital or skilled nursing facility.The benefit period ends when the Member has not 

received hospital or skilled nursing facility care for 60 consecutive days. If the Member is admitted to a hospital after one (1) benefit period has ended, a 

new benefit period begins.The Member must pay the inpatient hospital deductible for each new benefit period.There is no limit on the number of 

benefit periods a Member can have. 

Pharmacy Program 

Updates 

Drug 

Benicar HCT 

Therapeutic Use 

Antihypertensive therapy 

2004 Drug Formulary Update 

The following is an update to the preferred drug 

list (PDL) for Oxford’s three-tier prescription drug 

benefit. Oxford reviews new drug products approved 

by the Food and Drug Administration (FDA) and 

reviews current products when new information 

becomes available. The following medications 

were reviewed by the Pharmacy and Therapeutics 

Committee in August and October 2003. Coverage 

for the listed items may be limited or excluded 

based on a Member’s eligibility or plan design. 

Additions: 

The following drugs have been added to Oxford’s 

preferred drug list. This means that Members with 

a three-tier prescription drug plan may pay a lower 

copayment as a result of the change to preferred 

(2nd tier) status. 

Emend 

Fuzeon 

Humira 

Deletions: 

Antiemetic 

HIV/AIDS therapy 

Rheumatoid arthritis 

The following drugs have been deleted from 

Oxford’s preferred drug list. This means that 

Members with a three-tier prescription drug 

plan may pay a higher copayment as a result of 

the change to non-preferred brand (3rd tier) 

status. A listing of generic and preferred brand 

alternatives is provided. Unless otherwise noted, 

all changes went into effect January 1, 2004. 


Drug Therapeutic Use Generic and Preferred 

Brand Alternatives 

Accutane Acne therapy isotretinoin (generic) 

Amicar syrup Hemostatic aminocaproic acid (generic) 

Amoxil Antibiotic — penicillin amoxicillin (generic) 

Aygestin Progestin norethindrone acetate (generic) 

Children’s Advil Suspension Non-steroidal anti-inflammatory ibuprofen (generic) 

CoLyte Bowel evacuant sodium sulfate/sodium/sodium 

bicarbonate/potassium chloride 

polyethylene glycols (generic) 

DDAVP solution/spray Misc. hormones desmopressin (generic) 

DesOwen Lotion Topical corticosteroid desonide (generic) 

Desquam-X Acne therapy benzoyl peroxide (generic) 

Dilaudid tablet/liquid Narcotic analgesic hydromorphone (generic) 

Drysol/Drysol Dab-O-Matic Astringent aluminum chloride (generic) 

Eldopaque Forte Misc. dermatological agent hydroquinone/ferric oxide (generic) 

Eldoquin Forte Misc. dermatological agent hydroquinone (generic) 

Endep Antidepressant amitriptyline (generic) 

Estratest/Estratest HS Estrogen combination methyltestosterone/estrogens, 

esterified (generic) 

Florinef Acetate Adrenal hormone fludrocortisone (generic) 

Lotrisone Cream Topical antifungal clotrimazole/betamethasone (generic) 

Mestinon tablet Myasthenia gravis pyridostigmine (generic) 

Myambutol Antimycobacterial ethambutol (generic) 

Nexium Ulcer therapy omeprazole (generic) 

Paxil Antidepressant paroxetine (generic) 

Pediapred Adrenal hormone prednisolone sodium phosphate 

(generic) 

Permax Antiparkinsonism agent pergolide (generic) 

ProctoCream-HC 2.5% Misc. gastrointestinal agent hydrocortisone (generic) 

Rythmol Antiarrhythmic propafenone (generic) 

Spectazole Topical antifungal econazole (generic) 

Tambocor Antiarrhythmic flecainide (generic) 

Zarontin Anticonvulsant ethosuximide (generic) 


No Change: 

There has been no change in the formulary status of the following drugs. This means that Members with a 

three-tier prescription drug plan will continue to pay a higher copayment as a result of the non-preferred 

(3rd tier) brand status. A listing of generic and preferred brand alternatives is provided. 

Drug Therapeutic Use Generic and Preferred 

Brand Alternatives 

Finacea Acne therapy azelaic acid (generic), Metrocream, 

Metrogel 

Innopran XL Antihypertensive therapy propranolol (generic), Inderal LA 

Oxytrol Anticholinergic and antispasmodic oxybutynin (generic) 

Vigamox Antibiotic — ophthalmic Ocuflox 

Zymar Antibiotic — ophthalmic Ocuflox 

Quantity Limit Updates 

For certain medications, there may be a limit in the quantity covered at one time. This limit often reflects 

the maximum FDA-recommended dosage for a drug or use of the most efficient dosage strength for the 

fully prescribed daily dose. The following quantity limits were approved by the Pharmacy and Therapeutics 

Committee in October 2003. 

Drug Name Retail (one-month supply) Mail-order (three-month supply)* 

Avandamet (2 mg/1000 mg 60 tablets 180 tablets 

and 4 mg/1000 mg) 

Crestor (5, 10, 20, and 40 mg) 30 tablets 90 tablets 

Levitra (2.5, 5, 10, and 20 mg) 7 tablets per 30 days Drug not covered through mail-order 

Zomig Nasal Spray 8 nasal sprays per 30 days Drug not covered through mail-order 

* Applicable for those Members with mail-order coverage through their prescription drug benefit. 

Medications Requiring Precertification 

For most Members with pharmacy benefit coverage 

through Oxford, the drugs on the following list 

(including their generic alternatives, if available) 

generally require precertification, through Medco 

Health, based on Oxford’s coverage criteria. 

To obtain precertification, please call Medco 

Health at 1-800-753-2851, Monday through 

Friday, 8 AM to 9 PM. 

Physicians may be asked to provide information 

explaining medical necessity and past therapeutic 

failures. A representative will collect all pertinent 

clinical data relevant to the service requested. For 

those requests that do not meet the criteria for 

approval, physicians will be informed that coverage 

determination requires further review by an Oxford 

Medical Director. Physicians will receive notification 

of all decisions upon receipt of all necessary 

information required to render a decision. 

The following is an updated list of commonly 

used outpatient prescription drugs that currently 

require precertification. 


Anabolic steroids*/androgens* 

• Anadrol — 50 • Androderm patches 

• Androgel 

• Android 

• Deca Durabolin • Delatestryl 

• Depo Testosterone • Halotestin 

• Methyltestosterone • Oxandrin 

• Striant 

• Testim 

• Testoderm 

• Testosterone 

• Testred 

• Winstrol 

CNS stimulants 

• Adderall 1 • Concerta 1 

• Desoxyn 1 • Dexedrine 1 

• Dextrostat 1 

• Provigil 

Acne drugs 

• Avita 2 • Differin 2 

• Retin A 2 

Proton pump inhibitors* 

• Aciphex 

• Nexium 

• Prevacid 

• Prilosec 

• Protonix 

Misc. gastrointestinal drugs* 

• Lotronex 

• Zelnorm 

Erectile dysfunction drugs** 

• Caverject 

• Edex 

• Cialis 

• Levitra 

• Muse 

• Viagra 

Arthritis drugs 

• Bextra* 

• Celebrex* 

• Enbrel 

• Humira 

• Kineret 

• Vioxx* 

Specialized OB/GYN drugs 

• Lupron (3.75 mg & 11.25 mg) 

Misc. drugs 

• Forteo • Nutritional therapies 3 

• Serostim • Singulair 4 * 

• Strattera • Vitamin D preparations 

(i.e. Hectorol, Rocaltrol, etc.) 

1 Applies only to Members age 19 or older. 


3 For coverage information, Members should contact Oxford 

Customer Service at the number on their ID card. 


Please note: Precertification requirements may vary, 

depending on the Member’s benefit. 

*Precertification is not required for Oxford Medicare Advantage SM 

Members. 

** Medication is not covered for Oxford Medicare Advantage Members. 

To obtain precertification, please call Medco 

Health at 1-800-753-2851, Monday through Friday, 

from 8 AM to 9 PM (Eastern Standard Time). 

This list is subject to change without notice. 

For the most up-to-date information, please call 

Pharmacy Customer Service at 1-800-905-0201. 

Radiology Program 

Updates 

Referring Provider Update 

Effective January 1, 2004, we began notifying 

Members if they have been referred to a 

non-participating provider when there are 

participating providers who can perform 

the service. The notification explains that if 

a Member has out-of-network benefits, the 

reimbursement to the non-participating 

provider is subject to the Member’s out-ofnetwork 

deductible and coinsurance charges. 

It also clarifies that services requested for 

Members who do not have out-of-network 

benefits (i.e., HMO plan Members) are denied 

if it is requested that a non-participating 

provider performs the procedure. 

Precertification Update 

CareCore now provides a secure web-based process 

to initiate clinical certification for diagnostic 

imaging requests. The automated system guides 

the user through a series of computer screen 

prompts to collect routine demographic data. 

Each web-initiated request is evaluated promptly 

by CareCore’s clinical review staff. A return call from 

CareCore to the requester completes the certification 

process. This eliminates the need for a call to 

CareCore’s intake staff and conveniently allows the 

user to enter multiple clinical certification requests. 


Oxford Participating 

Hospitals 

We have provided a list of all Oxford participating 

hospitals in Connecticut, Delaware, New Jersey, 

New York, and Pennsylvania. The listing includes 

each hospital’s Oxford provider ID number 

(necessary for Oxford’s electronic referral process) 

and Oxford network affiliation with our plans 

(e.g., Freedom Plan, ® Liberty Plan SM [NY and NJ 

only] or Oxford Medicare Advantage SM [OMA].) 

This list is current as of November 1, 2003. 

Most hospital services require precertification. 

Please refer to Oxford’s Provider Reference Manual 

to verify which services require precertification. 

If you are referring a Member for a service that 

requires precertification, please call 1-800-666-1353. 

Participating providers can issue hospital referrals 

for services that do not require precertification, 

such as diagnostic testing. When entering the 

Oxford provider ID number of the hospital to 

which you are referring a Member, please be 

certain to use the letter O instead of the numeral 0. 

For example, the provider ID number for Bristol 

Hospital [HO4722] should be entered as the letter 

“H”, the letter “O”, then the numerals 4722. 

Connecticut Hospitals 

Oxford Facility Name County Freedom Oxford Medicare 

Provider ID Plan Advantage 

HO4982 Bradley Memorial Hospital Hartford X 

HO3178 Bridgeport Hospital Fairfield X 

HO4722 Bristol Hospital Hartford X 

HO9265 Charlotte Hungerford Hospital Litchfield X 

HO9999 Connecticut Children’s Medical Center Hartford X 

HO3177 Danbury Hospital Fairfield X 

HO3414 Day Kimball Hospital Windham X 

HO4040 Greenwich Hospital Fairfield X 

HO3255 Griffin Hospital New Haven X X 

HO1316 Hartford Hospital Hartford X 

HO3446 Hospital of Saint Raphael New Haven X X 

HO5555 Johnson Memorial Hospital Tolland X 

HO4961 Lawrence and Memorial Hospital New London X 

HO4254 Manchester Memorial Hospital Hartford X 

H2848683 Masonic Health Care Center New Haven X X 

H378840 Middlesex Hospital Middlesex X 

HO4381 Milford Hospital New Haven X X 

HO2258 New Britain General Hospital Hartford X 


Connecticut Hospitals (continued) 



HO4479 New Milford Hospital Litchfield X 

HO3170 Norwalk Hospital Fairfield X 

HO2601 Rockville General Hospital Tolland X 

HO9863 Saint Francis Hospital and Medical Center Hartford X 

HO1112 Saint Mary’s Hospital New Haven X X 

HO4512 Saint Vincent’s Medical Center Fairfield X 

HO4380 Sharon Hospital Litchfield X 

HO3172 Stamford Hospital Fairfield X 

HO4491 UCONN Health Center — Hartford X 

John Dempsey Hospital 

HO1120 Waterbury Hospital New Haven X X 

HO4529 William W. Backus Hospital New London X 

HO1661 Windham Community Hospital Windham X 

HO4716 Yale New Haven Hospital New Haven X X 

Delaware Hospitals 



HO2064 Ai Dupont Institute of The 

Nemours Foundation New Castle X 

H2626881 Bay Health Medical Center — Kent X 

Kent General Campus 

H2647163 Christiana Hospital New Castle X 

H2626229 Saint Francis Hospital New Castle X 

H1048513 Wilmington Hospital Center New Castle X 

New Jersey Hospitals 

Oxford Facility Name County Freedom Liberty Oxford 

Provider Plan Plan Medicare 

ID 

Advantage 

HO4393 Atlantic City Medical Center Atlantic X X 

HO3055 Barnert Hospital Passaic X X 


New Jersey Hospitals (continued) 



ID 

Advantage 

HO3031 Bayonne Hospital Hudson X X X 

HO5880 Bayshore Community Hospital Monmouth X X 

HO4488 Beth Israel Hospital Passaic X X 

H507602 Burdette Tomlin Memorial Hospital Cape May X X 

HO1486 Capital Health System — Fuld Campus Mercer X X 

HO1526 Capital Health System — Mercer Campus Mercer X X 

HO3037 Centrastate Medical Center Monmouth X X 

HO3057 Chilton Memorial Hospital Morris X X 

HO3040 Christ Hospital Hudson X X X 

HO3032 Clara Maass Medical Center Essex X X 

HO3047 Columbus Hospital Essex X X 

HO3063 Community Medical Center Ocean X X 

HO1448 Cooper Hospital — University Camden X X 

Medical Center 

HO1330 Deborah Heart and Lung Center Burlington X X 

HO3036 Englewood Hospital and Medical Center Bergen X X 

HO5252 Greenville Hospital Hudson X X X 

HO2010 Hackensack Medical Center Bergen X X 

HO3038 Hackettstown Community Hospital Warren X X 

HO2200 Holy Name Hospital Bergen X X 

HO1100 Hospital Center at Orange Essex X X 

HO4402 Hunterdon Medical Center Hunterdon X X 

HO4276 Irvington General Hospital Essex X X 

HO5253 Jersey City Medical Center Hudson X X X 

HO4052 Jersey Shore University Medical Center Monmouth X X 

HO4208 John F. Kennedy Medical Center Middlesex X X 

HO3423 Kimball Medical Center Ocean X X 





ID 

Advantage 

HO4114 Lourdes Medical Center of Burlington X X 

Burlington County 

HO3060 Meadowlands Hospital Medical Center Hudson X X X 

HO1016 Medical Center at Princeton Mercer X X 

HO5665 Memorial Hospital of Salem Hospital Salem X X 

HO3044 Monmouth Medical Center Monmouth X X 

HO3046 Morristown Memorial Hospital Morris X X 

HO3175 Mountainside Hospital Essex X X 

HO4417 Muhlenberg Regional Medical Center Union X X 

HO3048 Newark Beth Israel Medical Center Essex X X 

HO3050 Newton Memorial Hospital Sussex X X 

HO3033 Our Lady of Lourdes Medical Center Camden X X 

HO3062 Overlook Hospital Union X X 

HO3051 Palisades General Hospital Hudson X X X 

HO1002 Pascack Valley Hospital Bergen X X 

HO4953 Rahway Hospital Union X X 

HO1294 Raritan Bay Medical Center — Old Bridge Middlesex X X 

HO1294 Raritan Bay Medical Center — Perth Amboy Middlesex X X 

HO3002 Riverview Medical Center Monmouth X X 

H378168 Robert Wood Johnson Hospital at Hamilton Mercer X X 

HO1111 Robert Wood Johnson Medical Center Middlesex X X 

HO3043 Saint Barnabas Medical Center Essex X X 

HO4729 Saint Clare’s Hospital — Boonton Morris X X X 

HO4729 Saint Clare’s Hospital — Denville Morris X X X 

HO4729 Saint Clare’s Hospital — Dover Morris X X X 

HO4729 Saint Clare’s Hospital — Sussex Sussex X X X 

HO4051 Saint Francis Hospital Hudson X X X 

HO3064 Saint Francis Medical Center Mercer X X 





ID 

Advantage 

HO4206 Saint James Hospital Essex X X 

HO3056 Saint Joseph’s Hospital and Medical Center Passaic X X 

HO3066 Saint Joseph’s Wayne Hospital Passaic X X 

HO4053 Saint Mary Hospital Hudson X X X 

HO1400 Saint Mary’s Hospital — Orange Essex X X 

HO1200 Saint Michael’s Medical Center Essex X X 

HO4263 Saint Peter’s Medical Center Middlesex X X 

HO5102 Shore Memorial Hospital Atlantic X X 

HO4472 Somerset Medical Center Somerset X X 

HO4115 South Jersey Hospital System — Bridgeton Cumberland X X 

HO4115 South Jersey Hospital System — Elmer Salem X X 

HO4115 South Jersey Hospital System — Millville Cumberland X X 

HO4498 Southern Ocean County Hospital Ocean X X 

HO4527 The Medical Center of Ocean County Ocean X X 

HO4758 Trinitas Hospital — Jersey Street Campus Union X X 

HO4220 Trinitas Hospital — William Street Campus Union X X 

HO6262 Underwood Memorial Hospital Gloucester X X 

HO4319 Union Hospital Union X X 

HO3058 Valley Hospital Bergen X X 

HO4582 Virtua Memorial Hospital Burlington X X 

Burlington County 

HO1015 Virtua West Jersey Hospital — Berlin Camden X X 

HO1015 Virtua West Jersey Hospital — Camden Camden X X 

HO1015 Virtua West Jersey Hospital — Marlton Burlington X X 

HO1015 Virtua West Jersey Hospital — Voorhees Camden X X 

HO4649 Warren Hospital Warren X X 

HO3042 West Hudson Hospital Hudson X X X 

HO5100 William B. Kessler Memorial Hospital Atlantic X X 


New York Hospitals 



ID 

Advantage 

HO4231 Bayley Seton Hospital Richmond X X X 

HO4750 Beth Israel Hospital North New York X X X 

HO3080 Beth Israel Medical Center New York X X X 

HO3093 Beth Israel Medical Center — Kings X X X 

Kings Highway Division 

HO1012 Blythedale Children’s Hospital Westchester X X 

H384535 Bon Secours Community Hospital Orange X X 

HO3443 Bronx Lebanon Hospital Bronx X X X 

HO3083 Brookdale Hospital Medical Center Kings X X X 

HO3146 Brookhaven Memorial Hospital Suffolk X X 

HO3101 Brooklyn Hospital Center Kings X X X 

HO4828 Brunswick Hospital Center Suffolk X X 

HO3084 Cabrini Medical Center New York X X 

HO3085 Calvary Hospital Bronx X X X 

HO4205 Catholic Medical Center of Queens X X X 

Brooklyn and Queens 

HO4216 Catholic Medical Center of Brooklyn Queens X X X 

and Queens — Mary Immaculate Hospital 

HO4207 Catholic Medical Center of Brooklyn and Queens X X X 

Queens — Saint John’s Queens Hospital 

HO4383 Catholic Medical Center of Brooklyn and Queens X X X 

Queens — Saint Joseph’s Hospital 

HO4413 Catholic Medical Center of Brooklyn and Kings X X X 

Queens — Saint Mary’s Hospital of Brooklyn 

H2625762 Catskill Regional Medical Center Sullivan X 

HO3149 Central Suffolk Hospital Suffolk X X 

HO3071 Community Hospital at Dobbs Ferry Westchester X 

HO4224 Coney Island Hospital Kings X X X 

HO4436 Cornwall Hospital Orange X X 


New York Hospitals (continued) 



ID 

Advantage 

H377164 Eastern Long Island Hospital Suffolk X X 

H522312 Ellenville Regional Hospital Ulster X 

H946659 Elmhurst Hospital Center Queens X X X 

HO3088 Flushing Hospital and Medical Center Queens X X X 

HO3166 Franklin Hospital Medical Center — Nassau X X X 

Member of North Shore Long Island 

Jewish Health System 

HO3129 Good Samaritan Hospital — Suffern Rockland X X 

HO3167 Good Samaritan Hospital — West Islip Suffolk X X 

HO3090 Hospital for Joint Diseases New York X X X 

HO3091 Hospital for Special Surgery New York X X 

HO5080 Hudson Valley Hospital Center at Westchester X X 

Peekskill/Cortlandt 

HO3138 Huntington Hospital — Member of Suffolk X X X 

North Shore Long Island Jewish 

Health System 

HO3092 Jamaica Hospital Queens X X X 

H406390 John T. Mather Memorial Hospital Suffolk X 

HO4317 Kingsbrook Jewish Medical Center Kings X X 

HO4589 Kingston Hospital Ulster X 

HO3069 Lawrence Hospital Westchester X X 

HO3095 Lenox Hill Hospital New York X X X 

HO3140 Long Beach Medical Center Nassau X X 

HO3097 Long Island College Hospital Kings X X X 

HO3102 Long Island Jewish Medical Center — Nassau X X X 



HO4049 Lutheran Medical Center Kings X X X 

HO4400 Maimonides Medical Center Kings X X 





ID 

Advantage 

HO3103 Manhattan Eye, Ear and Throat New York X X X 

HO3160 Mercy Medical Center Nassau X X X 

HO3114 Montefiore Medical Center Bronx X X X 

HO3115 Montefiore Medical Center — Bronx X X X 

Einstein Division 

HO3077 Mount Sinai Hospital of Queens Queens X X X 

HO4238 Mount Sinai Medical Center New York X X X 

HO3075 Mount Vernon Hospital Westchester X X 

H792190 Nassau University Medical Center Nassau X X 

HO3153 New Island Hospital Nassau X X 

HO3107 New York Eye and Ear Infirmary New York X X X 

HO3081 New York Hospital Medical Center of Queens Queens X X X 

HO4281 New York Methodist Hospital Kings X X X 

HO1248 New York Presbyterian Hospital — New York X X X 

Allen Pavilion 


Cornell Campus 


Presbyterian Campus 

HO4000 New York University Hospitals Center New York X X 

HO4204 New York Westchester Square Medical Center Bronx X X X 

HO1488 North General Hospital New York X X X 

H367349 North Shore University Hospital — Forest Hills Queens X X X 

HO4801 North Shore University Hospital — Glen Cove Nassau X X X 

HO3141 North Shore University Hospital — Manhasset Nassau X X X 

HO3147 North Shore University Hospital — Plainview Nassau X X X 

H378175 North Shore University Hospital — Syosset Nassau X X X 

HO1504 Northern Dutchess Hospital Dutchess X 





ID 

Advantage 

HO3074 Northern Westchester Hospital Center Westchester X X 

HO4869 Nyack Hospital Rockland X X 

HO4218 NYU Downtown Hospital New York X X X 

HO4282 Orange Regional Medical Center — Orange X X 

Arden Hill Campus 

HO4326 Orange Regional Medical Center — Orange X X 

Horton Campus 

HO3109 Our Lady of Mercy Medical Center Bronx X X X 

HO3183 Parkway Hospital Queens X X X 

HO4644 Peninsula Hospital Center Queens X X 

HO3125 Phelps Memorial Hospital Center Westchester X X 

HO3070 Putnam Hospital Center Putnam X X 

HO4200 Queens Hospital Center Queens X X X 

HO4399 Saint Anthony Community Hospital Orange X X 

HO4366 Saint Barnabas Hospital Bronx X X X 

H2018325 Saint Catherine of Siena Medical Center Suffolk X X 

HO3168 Saint Charles Hospital Suffolk X X 

HO4608 Saint Clares Hospital and Health Center New York X X 

HO4571 Saint Francis Hospital Dutchess X 

HO1069 Saint Francis Hospital Nassau X X 

HO4391 Saint John’s Episcopal Hospital — South Shore Queens X X X 

HO3135 Saint John’s Riverside Hospital Westchester X X 

HO4501 Saint Joseph’s Medical Center Westchester X X 

HO4235 Saint Luke’s — Roosevelt Hospital Center New York X X X 

HO4201 Saint Luke’s Hospital — Newburgh Orange X X 

HO4217 Saint Vincent’s Hospital and Medical Center New York X X X 

HO3182 Saint Vincent’s Medical Center of Richmond Richmond X X X 

HO3076 Sound Shore Medical Center Westchester X X 





ID 

Advantage 

HO3145 South Nassau Community Hospital Nassau X X 

HO4447 Southampton Hospital Suffolk X X 

HO3068 Southside Hospital — Member of North Suffolk X X X 

Shore Long Island Jewish Health System 

HO4534 State University Hospital of Brooklyn Kings X X X 

HO1666 Staten Island University Hospital: Concord Richmond X X X 

Site — Member of North Shore Long 

Island Jewish Health System 

HO3123 Staten Island University Hospital: North — Richmond X X X 



HO3123 Staten Island University Hospital: South — Richmond X X X 



HO3086 The New York Community Hospital Kings X X X 

of Brooklyn 

HO3127 United Hospital Medical Center Westchester X X 

HO4212 University Hospital SUNY at Stonybrook Suffolk X 

HO5540 Vassar Brothers Hospital Dutchess X X 

HO4245 Victory Memorial Hospital Kings X X X 

HO4302 Westchester Medical Center Westchester X X 

HO3134 White Plains Hospital Center Westchester X X 

HO3142 Winthrop University Hospital Nassau X X 

HO3124 Wyckoff Heights Hospital Kings X X X 

Pennsylvania Hospitals 

Oxford Facility Name County Freedom 

Provider ID 

Plan 

HO5003 Abington Hospital Montgomery X 

HO1096 Albert Einstein Medical Center Philadelphia X 

HO1008 Albert Einstein Medical Center — Northern Division Philadelphia X 

HO6457 Allegheny University Hospital Philadelphia X 

H597341 American Oncologic Hospital T/A Fox Chase Cancer Philadelphia X 


Pennsylvania Hospitals (continued) 


Provider ID 

Plan 

HO7010 Brandywine Hospital Chester X 

HO4412 Bryn Mawr Hospital Delaware X 

H2558708 Central Montgomery Medical Center Montgomery X 

HO1315 Chestnut Hill Hospital Philadelphia X 

HO1048 Children’s Hospital of Philadelphia Philadelphia X 

H2578093 Crozer Chester Medical Center — Community Division Delaware X 

H2578100 Crozer Chester Medical Center — Springfield Division Delaware X 

H2578112 Crozer Chester Medical Center Delaware X 

HO6014 Crozer-Taylor-Springfield Delaware X 

HO6015 Delaware County Memorial Hospital Delaware X 

HO4337 Doylestown Hospital Bucks X 

HO7025 Episcopal Hospital Philadelphia X 

HO4279 Frankford Hospital Philadelphia X 

H2584728 Frankford Hospital — Torresdale Campus Philadelphia X 

HO2021 Germantown Hospital Philadelphia X 

HO1113 Grand View Hospital Bucks X 

HO6460 Hahnemann University Hospital Philadelphia X 

HO3340 Holy Redeemer Hospital and Medical Center Montgomery X 

HO1340 Jeanes Hospital Philadelphia X 

H2538068 Jennersville Regional Hospital Chester X 

HO2609 JFK Memorial Hospital Philadelphia X 

HO3347 Lankenau Hospital Montgomery X 

HO3345 Mercy Community Hospital Delaware X 

HO3346 Mercy Fitzgerald Hospital Delaware X 

HO3344 Mercy Hospital of Philadelphia Philadelphia X 

H712666 Methodist Hospital Philadelphia X 

HO4406 Methodist Hospital, TJU Philadelphia X 

HO4568 Montgomery Hospital Montgomery X 

HO3337 Nazareth Hospital Philadelphia X 


Pennsylvania Hospitals (continued) 


Provider ID 

Plan 

HO7031 Neumann Medical Center Philadelphia X 

HO4647 North Penn Hospital Montgomery X 

HO4378 Northeastern Hospital Philadelphia X 

HO3348 Paoli Memorial Hospital Chester X 

HO4116 Pennsylvania Hospital Philadelphia X 

HO3375 Phoenixville Hospital Chester X 

HO3341 Presbyterian Medical Center Philadelphia X 

HO3339 Quakertown Community Hospital Bucks X 

HO3338 Riddle Memorial Hospital Delaware X 

HO6679 Roxborough Memorial Hospital Philadelphia X 

H2579157 Select Specialty Hospital — Philadelphia Philadelphia X 

H2579726 Specialty Hospital of Philadelphia Delaware X 

HO6461 Saint Christopher’s Hospital for Children Philadelphia X 

HO2607 Saint Joseph Medical Center Berks X 

HO3334 Saint Joseph Medical Center Berks X 

H2575230 Saint Joseph’s Medical Center — Community Care Berks X 

HO3335 Saint Mary Medical Center Bucks X 

H546697 Saint Agnes Medical Center Philadelphia X 

HO3333 Saint Agnes Medical Center Philadelphia X 

HO3342 Saint Joseph Hospital Philadelphia Philadelphia X 

HO4712 Suburban General Hospital Montgomery X 

H650252 Surgery Center of Bucks County Bucks X 

HO4551 Temple Lower Bucks Hospital Bucks X 

H833813 Temple University Children’s Hospital Philadelphia X 

HO6678 Temple University Hospital Philadelphia X 

HO4555 The Chester County Hospital Chester X 

HO1638 Thomas Jefferson University Hospital Philadelphia X 

HO3000 Villa Saint John Vianney Hospital Chester X 

H1084105 Warminster Hospital Bucks X 

HO1126 Wills Eye Hospital Philadelphia X 

Designed and printed by Onward Publishing, Inc. Northport, NY 11768 


there is another way® 

www.oxfordhealth.com 

MS-04-059 ©2004 Oxford Health Plans, Inc. 6891

1st Quarter 2004 - Oxford Health Plans

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