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High quality, low cost:
It’s what you get when you focus on what counts.

2. Primary Advantage Overview
Introducing Primary Advantage
Primary Advantage is a new Oxford product for Small and Large group employers in New York, New Jersey, and Connecticut who want to be part of the affordability solution. Primary Advantage is different, but easy to understand.
It helps employers save money upfront with a lower premium
Employees save money by focusing benefits on:
Preventive care, available at no cost
Primary care, low copayment
High value prescription drugs, low copayment
Primary Advantage provides high quality care and lower out of pocket costs for members who make the right choices.
~ 75% of health care encounters
fall under these categories 2
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3. Primary Advantage Overview
How the Plan Works
100% in-network preventative care coverage
Primary Care office visits & Tier 1 prescription drugs are covered with a copayment and no deductible
All other services, including Specialist care and Tier 2 and 3 prescription drugs, are subject to a combined deductible of either $1,500 or $2,500, depending on the plan chosen.
After the deductible is met, the member will pay a specified copayment (not coinsurance) for medical services, including specialist office visits.
Tier 2 and 3 prescription drugs are covered with a 50% coinsurance after the combined deductible is met.
While there are no referrals required to see a specialist, this plan design encourages members to seek care from their primary care physician whenever possible. 3
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4. Primary Advantage Overview
Network Access
National Network Access -51+ groups have in-network access to the Choice Plus National Network outside the tri-state service area
2-50 groups have in-network access within the tri-state service area only
(Emergency Services are covered nationwide)
Key Talking Points
Approximately 75% of ALL health care encounters are covered outside of the deductible
At least 99% of drugs in T2 & 3 have a T1 alternative available
Generic utilization is ~ 75%
Tier 1
73-75%
Tier 2
12-15%
Tier 3
10-13%
Average Utilization 4
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5. Primary Advantage Overview
Getting the most from their benefits
No cost for Preventative Care including:
Annual physicals for adults,
preventive care for children,
well woman care through an OB/GYN
other important screenings
We encourage members to seek care from their primary care physician before they seek care from a specialist. A visit to your primary care physician can be a much smarter choice than other care options. The chart below shows the average cost to a member enrolled in the Primary Advantage plan for frequently used services. As you can see, once the deductible is met, there are still significant savings opportunities gained by seeking care from a primary care physician.
Note: Costs may vary
based on fee schedules
of providers
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6. Primary Advantage Overview
Primary Advantage Plan in Action: Meet Jane.
Meet Jane, a health member with 2 children enrolled in the Primary Advantage plan. The chart below compares Jane’s costs for a year when maximizing Primary Advantage cost savings benefit choices (“best choice”) vs. making decisions where out-of-pocket costs are the highest (“other options”). By making the “best choices” throughout the year, Jane saves $899.
Jane saves by focusing her choices on
Primary Care and Tier 1 drugs
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7. Primary Advantage Overview
Important Dates - Connecticut
Key Accounts
Proposal Ready – 7/1/12
Case Effective – 9/1/12
Broker eUpdate – targeting 6/25/12
Small Business
Proposal Ready – 5/1/11
Case Effective – 7/1/12
Broker teaser – 4/11/12
Broker eUpdate – 4/23/12
Marketing Materials:
Primary Advantage Launch Brochure (B2B)
Primary Advantage Broker eBlast
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8. Primary Advantage Overview
Out of Area Plan recommendation
For groups, both 2-50 and 51+, that have membership residing outside the tri-state area, they must choose an Ox-USA plan. However, OxUSA plans were not created for Primary Advantage in efforts to get the plan out in a timely manner, so we recommend the following OxUSA plans that most closely match the Primary Advantage design(s).
Primary Advantage 1500
Primary Advantage 2500
CT SG
Direct 10
Direct 11
CT LG
Direct Plan 6
Direct Plan 7
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9. Primary Advantage Overview
CONNECTICUT: PLAN 1
CONNECTICUT: PLAN 2
COVERED SERVICES
IN-NETWORK MEMBER COST
Primary Care Physician (PCP) or OB/GYN Office Visit
$25 copayment
$30 copayment
Preventive Care
100%
Prescription Drugs (Tier 1 only)
$15 copayment per prescription; $30 copayment for 90-day mail order supply
$15 copayment per prescription; $30 copayment for 90-day mail order supply
All other services are subject to the deductible
Contract Year Deductible (Single/Family)
$1,500 Single / $3,750 Family
$2,500 Single / $6,250 Family
IN-NETWORK MEMBER COST AFTER DEDUCTIBLE
Specialty Care Services
$45 copayment
Emergency Services
Urgent Care Center
Hospital Emergency Room Visit
$150 copayment (waived if admitted)
Ambulance
$100 copayment
Inpatient Hospitalization
$250 copayment per day; 5 day limit per admission
$400 copayment per day; 5 day limit per admission
Outpatient Laboratory Services
Outpatient Radiology and Diagnostic Services
Major: $75 copayment Minor: $45 copayment
Outpatient Surgery
$150 copayment
$250 copayment
Durable Medical Equipment (DME)
Outpatient Mental Health Care & Substance Abuse Services
Inpatient Hospital Care and Residential Crisis Services (up to 60 days per contract year)
Physician Inpatient Services
Prescription Drugs (Tier 2 and Tier 3 - including self-injectibles)
50% to maximum of $250 per 31 day retail supply script; $500 maximum on mail order. Self-injectibles not available through mail order.
50% to maximum of $400 per 31 day retail supply script; $800 maximum on mail order. Self-injectibles not available through mail order.
Out-of-Pocket Limit (Single/Family) (Includes deductible, copayments and coinsurance Excludes pharmacy, with the exception of the pharmacy out-of-pocket expenses applied to the deductible.)
$7,500 Single / $18,750 Family
$7,500 Single / $18,751 Family 9

10. Small Business Plan Changes
Proposal Ready: 5/1/12
Effective Date: 7/1/12
New Plans designs:
Primary Advantage
Addition of 2 new Direct Plans:
$30/$45, $3000 ded, 80% coinsurance
$30/$45, $5000 ded, 80% coinsurance
Direct 50% Plan
PCP=$30
$2500 deductible
50% coinsurance
New HSA Plans:
$2000 deductible w/copays after deductible (CTLG as well, 9/1/12)
$3000 deductible w/copays after deductible (CTLG as well, 9/1/12)
$4000 deductible, 90% coinsurance
Portfolio reduction:
Portfolio reduction – down to 25 plan designs

11. Key Account Plan Changes
Proposal Ready: 7/1/12
Effective Date: 9/1/12
New Plans designs:
Primary Advantage
Split Copay options for HMO, HMO Select, POS and POS Select:
$15/$30
$25/$40
$30/$45
New HSA Plans:
$2,000 deductible w/copays after deductible
$3,000 deductible w/copays after deductible
HSA Plan 7 - $5000 deductible, 90% coinsurance
Update coinsurance maximum to $10,000
Current coinsurance maximum is $5,950

12. Questions
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