Your Medicare Health Benefits andServices/Prescription Drug Coverage as a Member ofAdvantra Gold HMOThis mailing gives you the details about your Medicare health and/or prescription drugcoverage from January 1 – December 31, 2009, and explains how to get the health careand/or prescription drugs you need. This is an important legal document. Please keep it ina safe place.Advantra Customer Services:For help or information, please call Customer Services or go to our Plan Website .1-800-290-0190 (Calls to these numbers are free)TTD users call: 1-800-207-1262Hours of Operation for Customer ServicesNovember 15, 2008 – March 1, 2009 Monday – Friday, 8:00 a.m. – 8:00 p.m. Saturday, 9:00 a.m. – 3 p.m. Eastern TimeMarch 2, 2009 – November 14, 2009 Monday – Friday, 8:00 a.m. – 6:00 p.m. Eastern TimeMedicare Prescription Drug (Part D)24 hours a day; seven days a week, including holidaysThis Plan is offered by HealthAmerica, referred throughout the EOC as “we”, “us”or “our.” Advantra is referred to as “Plan” or “our Plan.” Our organizationcontracts with the Federal government.This information may be available in a different format, including audio versions. Pleasecall Customer Services at the number listed above if you need plan information in anotherformat or language.EPHMA017M0003 09H3959 212 Plan002(10/7/08)

2009 Evidence of Coverage (EOC)This is Your 2009 Evidence of Coverage(EOC)Table of Contents1. Introduction. 32. How You Get Care and Prescription Drugs. 123. Your Rights and Responsibilities as a Member of our Plan . 314. How to File a Grievance . 415. Complaints and Appeals about your Part D Prescription Drug(s) and/or Part CMedical Care and Service(s). 446. Ending your Membership . 647. Definitions of Important Words Used in the EOC. 688. Helpful Phone Numbers and Resources . 759. Legal Notices . 8010. How Much You Pay for Your Part C Medical Benefits and/or Part D PrescriptionDrugs. 82General Exclusions . 102Index . 1072

2009 Evidence of Coverage (EOC)1. IntroductionThank you for being a member of our Plan!This is your Evidence of Coverage, which explains how to get your Medicare health careand/or drug coverage through our Plan, an HMO. You are still covered by Medicare, butyou are getting your health care and/or Medicare prescription drug coverage through ourPlan.This Evidence of Coverage, together with your enrollment form, riders, formulary, andamendments that we send to you, is our contract with you. The Evidence of Coverageexplains your rights, benefits and responsibilities as a member of our Plan and is in effectfrom January 1, 2009 - December 31, 2009. Our plan’s contract with the Centers forMedicare & Medicaid Services (CMS) is renewed annually, and availability of coveragebeyond the end of the current contract year is not guaranteed.This Evidence of Coverage will explain to you: What is covered by our Plan and what isn’t covered. How to get the care you need or your prescriptions filled, including some rulesyou must follow. What you will have to pay for your health care or prescriptions. What to do if you are unhappy about something related to getting your coveredservices or prescriptions filled. How to leave our Plan, and other Medicare options that are available, includingyour options for continuing Medicare prescription drug coverage.This Section of the EOC has important information about: Eligibility requirements The geographic service area of our Plan Keeping your membership record up-to-date Materials that you will receive from our Plan Paying your plan premiums Late enrollment penalty Extra help available from Medicare to help pay your plan costsEligibility RequirementsTo be a member of our Plan, you must live in our service area, be entitled to MedicarePart A, and enrolled in Medicare Part B and not have End Stage Renal Disease (ESRD),with limited exceptions, such as if you are already a member of our plan. If you currentlypay a premium for Medicare Part A and/or Medicare Part B, you must continue payingyour premium in order to keep your Medicare Part A and/or Medicare Part B and remaina member of this plan.3

2009 Evidence of Coverage (EOC)The geographic service area for our PlanThe state and counties in our service area are listed below.Armstrong, Beaver, Bedford, Butler, Clearfield, Crawford, Erie, Fayette, Greene,Lawrence, Mercer, Washington and Westmoreland Counties, PennsylvaniaHow do I keep my membership record up to date?We have a membership record about you. Your membership record has information fromyour enrollment form, including your address and telephone number. It shows yourspecific Plan coverage, including the Primary Care Physician/Medical Group you choseand other information. Doctors, hospitals, pharmacists and other network providers useyour membership record to know what services or drugs are covered for you. Section 3tells how we protect the privacy of your personal health information.Please help us keep your membership record up to date by telling Customer Services ifthere are changes to your name, address, or phone number, or if you go into a nursinghome. Also, tell Customer Services about any changes in other health insurancecoverage you have, such as from your employer, your spouse’s employer, workers’compensation, Medicaid, or liability claims such as claims from an automobile accident.Materials that you will receive from our PlanPlan membership cardWhile you are a member of our Plan, you must use our membership card for servicescovered by this plan and/or prescription drug coverage at network pharmacies. While youare a member of our Plan you must not use your red, white, and blue Medicare card to getcovered services, items and/or drugs. Keep your red, white, and blue Medicare card in asafe place in case you need it later. If you get covered services using your red, white, andblue Medicare card instead of using our membership card while you are a plan member,the Medicare Program won’t pay for these services and you may have to pay the full costyourself.Please carry your membership card that we gave you at all times and remember to showyour card when you get covered services, items and/or drugs. If your membership card isdamaged, lost, or stolen, call Customer Services right away and we will send you a newcard.The Provider Directory gives you a list of network providersand network pharmaciesEvery year that you are a member of our Plan, we will send you either a ProviderDirectory or an update to your Provider Directory, which lists our network providers andnetwork pharmacies. If you don’t have the Provider Directory, you can get a copy fromCustomer Services. You may ask Customer Services for more information about ournetwork providers, including their qualifications. Customer Services can give you the4

2009 Evidence of Coverage (EOC)most up-to-date information about changes in our network providers and about whichones are accepting new patients. A complete list of network providers and networkpharmacies is available on our website: must use network providers for services to be covered by us at plan cost-sharinglevels, except in emergencies, for urgently needed care out-of-area, or for out of the areadialysis services. See the benefits chart in Section 10 for more specific out-of-networkcoverage information.The Pharmacy Directory section in The Provider Directorygives you a list of Plan network pharmaciesWe include in the Provider Directory a complete Pharmacy Directory, which gives you alist of our network pharmacies. You will receive the Provider Directory including thePharmacy Directory at least every three years, and an update of our Provider andPharmacy Directory every year that we don’t send you a complete Provider Directory.You can use it to find the network pharmacy closest to you. If you don’t have theProvider and Pharmacy Directory, you can get a copy from Customer Services. They canalso give you the most up-to-date information about changes in this Plan’s pharmacynetwork, which can change during the year. You can also find this information on ourwebsite.Part D Explanation of BenefitsWhat is the Explanation of Benefits?The Explanation of Benefits (EOB) is a document you will get for each month you useyour Part D prescription drug coverage. The EOB will tell you the total amount you havespent on your prescription drugs and the total amount we have paid for your prescriptiondrugs. An Explanation of Benefits is also available upon request. To get a copy, pleasecontact Customer Services.What information is included in the Explanation of Benefits?Your Explanation of Benefits will contain the following information: A list of prescriptions you filled during the month, as well as the amount paidfor each prescription; Information about how to request an exception and appeal our coveragedecisions; A description of changes to the formulary that will occur at least 60 days inthe future and affect the prescriptions you have gotten filled; A summary of your coverage this year, including information about:o Amount Paid For Prescriptions-The amounts paid that counttowards your initial coverage limit.o Total Out-Of-Pocket Costs that count toward CatastrophicCoverage-The total amount you and/or others have spent onprescription drugs that count towards you qualifying for catastrophiccoverage. This total includes the amounts spent for your coinsurance5

2009 Evidence of Coverage (EOC)or co-payments and payments made on covered Part D drugs after youreach the initial coverage limit. (This amount doesn’t includepayments made by your current or former employer/union, anotherinsurance plan or policy, a government-funded health program or otherexcluded parties).Your monthly plan premiumThe monthly premium amount described in this section does not include any lateenrollment penalty you may be responsible for paying (see “What is the MedicarePrescription Drug Plan late enrollment penalty?” later in this section for moreinformation).As a member of our Plan, you pay:1) Your monthly Medicare Part B premium. Most people will pay the standard premiumamount, which is 96.40 in 2009. (Your Part B premium is typically deducted fromyour Social Security payment.) (If you receive benefits from your state Medicaidprogram, all or part of your Part B premium may be paid for you.)2) Your monthly Medicare Part A premium, if necessary (most people don’t have to paythis premium).3) Your monthly premium for our Plan.Your monthly premium for our Plan is listed in Section 10. If you have any questionsabout your Plan premiums or the payment programs, please call Customer Services.As a member of our Plan, you pay a monthly plan premium. (If you qualify for extra helpfrom Medicare, called the Low-Income Subsidy or LIS, you may not have to pay for allor part of the monthly premium)If you get benefits from your current or former employer, or from your spouse’s currentor former employer, call the employer’s benefits administrator for information about yourmonthly plan premium.Note: If you are getting extra help (LIS) with paying for your drug coverage, thepremium amount that you pay as a member of this Plan is listed in your “Evidence ofCoverage Rider for those who Receive Extra Help for their Prescription Drugs”. Or, ifyou are a member of a State Pharmacy Assistance Program (SPAP), you may get helppaying your premiums. Please contact your SPAP at the phone number listed in Section 8to determine what benefits are available to you.6

2009 Evidence of Coverage (EOC)Monthly Plan Premium Payment OptionsThere are two ways to pay your monthly plan premium. When you enroll in our plan, youcan tell us on your application how you want to pay your premium. If you decide that youwant to change you premium payment method, call Customer Services.Option one: Pay your monthly plan premium directly to our Plan.You may decide to pay your monthly plan premium directly to our Plan. You will besent a coupon book for your monthly payments to be made by check. Payments are dueon the 10th of the month. The address for payment will be printed on your coupon book.If you lose your coupon book, you will need to call the Customer Services number onyour ID card for a replacement book.Instead of paying by check, you can have your monthly plan premium automaticallywithdrawn from your checking account. The deduction will always take place on the 10thof the month for that month’s premium. You will need to check the appropriate box onthe application form and provide a voided check. The signature of the account holder isrequired. It cannot be a business check, unless your name is on the check itself. Pleasecall the Customer Services number on your ID card if you have any questions aboutsetting up this payment process.Option two: You may have your monthly plan premium directlydeducted from your monthly Social S