2009 Plans

Today’s Options^® PPO Medicare Advantage Plan comes with an extensive network of doctors and hospitals, but we offer coverage on out-of-network visits as well. Plans also feature low co-pays, premiums and deductibles; annual out-of-pocket limit for medical expenses; and much more.

What plan is right for you?

• Plan summary for Select and Select powered by CCRx
• Plan summary for Complete powered by CCRx

For more detailed information, review the Summary of Benefits.

Plan Summary - Select Plans Select Select powered by CCRx Network Out-of-Network Network Out-of-Network Monthly Premium As low as $0 As low as $0 As low as $0 As low as $0 MEDICAL BENEFITS Annual Out-of-Pocket Limit $2,500 N/A $2,500 N/A PCP/Specialist Co-pay $10/$25 $35/$35 $10/$25 $35/$35 Inpatient Hospital Care $195 per stay $800 per stay $195 per stay $800 per stay Emergency Care Co-pay per visit $50 $50, Worldwide coverage $50 $50, Worldwide coverage PART D PRESCRIPTION DRUG COVERAGE Deductible No Coverage No Coverage $0 $0 Initial Drug Coverage No Coverage No Coverage up to $2700 up to $2700   30-day/90-day supply, you pay 30-day/90-day supply, you pay Generics No Coverage No Coverage $5/$15 $5 Preferred Brands No Coverage No Coverage $30/$90 $30 Non-preferred Brands No Coverage No Coverage $60/$180 $60 Specialty Drugs No Coverage No Coverage 25% coinsurance 25% coinsurance Coverage Gap Benefits No Coverage No Coverage $5/$15 for generics $5 for generics Catastrophic Coverage after you reach $4,350 in out-of-pocket prescription drug expenses Generics No Coverage No Coverage The greater of 5% coinsurance or $2.40 The greater of 5% coinsurance or $2.40 Brands No Coverage No Coverage The greater of 5% coinsurance or $6 The greater of 5% coinsurance or $6

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Plan Summary - Complete Complete powered by CCRx Available in Charleston, West Virginia; Billings, Montana; Williamsport, Pennsylvania; Portland, Maine; Milwaukee/Green Bay, Wisconsin Recommended for those who qualify for assistance from Medicaid. Complete powered by CCRx Available in York/Erie, Pennsylvania; Omaha, Nebraska; Indianapolis, Indiana Recommended for those who qualify for assistance from Medicaid. Network Out-of-Network Network Out-of-Network Monthly Premium $0- $22 $0- $22 $0 - $20.70 $0 - $20.70 MEDICAL BENEFITS Annual Out-of-Pocket Limit $3,000 $500 yearly deductible. Contact the plan for services that apply. N/A N/A PCP/Specialist Co-pay $0/$25 $35/$35 20% coinsurance/20% coinsurance 20% coinsurance/20% coinsurance Inpatient Hospital Care • Days 1-5: $250 co-pay • Days 6-90: $0 co-pay $800 co-pay for each hospital stay • Days 1-60: $1,068 deductible • Days 61-90: $267/day • Days 91-150: $534/lifetime reserve day Emergency Care $50 co-pay $25,000 limit for emergency services outside the U.S. every year. 20% of the cost (up to $50) for Medicare-covered emergency room visits PART D PRESCRIPTION DRUG COVERAGE Deductible $295 yearly $295 yearly Initial Drug Coverage After deductible, you pay 25% until yearly costs reach $2,700. After deductible, reimbursement up to 75% drug cost purchased out-of-network until yearly costs reach $2,700. After deductible, you pay 25% until yearly costs reach $2,700. After deductible, reimbursement up to 75% drug cost purchased out-of-network until yearly costs reach $2,700.   30-day/90-day supply, you pay 30-day/90-day supply, you pay Generics 25% coinsurance 25% coinsurance 25% coinsurance 25% coinsurance Preferred Brands 25% coinsurance 25% coinsurance 25% coinsurance 25% coinsurance Non-preferred Brands No Coverage 25% coinsurance 25% coinsurance 25% coinsurance Specialty Drugs 25% coinsurance 25% coinsurance 25% coinsurance 25% coinsurance Coverage Gap After $2,700, you pay 100% until yearly out-of-pocket costs reach $4,350. After $2,700, you pay 100% of drugs purchased out-of network until yearly out-of-pocket costs reach $4,350. After $2,700, you pay 100% until yearly out-of-pocket costs reach $4,350. After $2,700, you pay 100% of the drugs purchased out of network until out-of-pocket costs reach $4,350. Catastrophic Coverage after you reach $4,350 in out-of-pocket prescription drug expenses Generics The greater of 5% coinsurance or $2.40 The greater of 5% coinsurance or $2.40 (including brand drugs treated as generic) The greater of 5% coinsurance or $2.40 The greater of 5% coinsurance or $2.40 Brands The greater of 5% coinsurance or $6 The greater of 5% coinsurance or $6 The greater of 5% coinsurance or $6 The greater of 5% coinsurance or $6

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