Introduction to the Summary of Benefits Report for INDEPENDENT

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					                     Introduction to the Summary of Benefits Report
          for INDEPENDENT HEALTH’S MEDICARE ANYWHERE BASIC
                      January 1, 2009 - December 31, 2009
                                     NEW YORK STATE

Thank you for your interest in Independent Health’s Medicare Anywhere Basic. Our
plan is offered by INDEPENDENT HEALTH BENEFITS CORPORATION/Independent
Health, a Medicare Advantage Private Fee-for-Service organization. This Summary of
Benefits tells you some features of our plan. It doesn’t list every service that we cover
or list every limitation or exclusion. To get a complete list of our benefits, please call
Independent Health’s Medicare Anywhere Basic and ask for the “Evidence of
Coverage.”

YOU HAVE CHOICES IN YOUR HEALTH CARE
As a Medicare beneficiary, you can choose from different Medicare options. One option
is the Original (fee-for-service) Medicare plan. Another option is a Medicare Advantage
Private Fee-for-Service plan, like Independent Health’s Medicare Anywhere Basic. You
may have other options too. You make the choice. No matter what you decide, you are
still in the Medicare program.
You may join or leave a plan only at certain times. Please call Independent Health’s
Medicare Anywhere Basic at the number listed at the end of this introduction or
1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call
1-877-486-2048. You can call this number 24 hours a day, 7 days a week.

HOW CAN I COMPARE MY OPTIONS?
You can compare Independent Health’s Medicare Anywhere Basic and the Original
Medicare Plan using this Summary of Benefits. The charts in this booklet list some
important health benefits. For each benefit, you can see what our plan covers and what
the Original Medicare Plan covers.
Our members receive all of the benefits that the Original Medicare Plan offers. We also
offer more benefits, which may change from year to year.

WHERE IS INDEPENDENT HEALTH’S MEDICARE ANYWHERE BASIC
AVAILABLE?

The service area for this plan includes: Albany, Allegany, Bronx, Broome, Cattaraugus,
Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware,
Dutchess, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson,
Kings, Lewis, Livingston, Madison, Monroe, Montgomery, Nassau, New York, Niagara,
Oneida, Onondaga, Ontario, Orange, Orleans, Oswego, Otsego, Putnam, Queens,
Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St.
Lawrence, Steuben, Suffolk, Sullivan, Tioga, Tompkins, Ulster, Warren, Washington,
Wayne, Westchester, Wyoming, Yates Counties, NY. You must live in one of these areas
to join the plan.
                                                               H9519_C1269rev 10/2008

H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)      1
                     Introduction to the Summary of Benefits Report
          for INDEPENDENT HEALTH’S MEDICARE ANYWHERE BASIC
                      January 1, 2009 - December 31, 2009
                                     NEW YORK STATE

WHO IS ELIGIBLE TO JOIN INDEPENDENT HEALTH’S MEDICARE ANYWHERE
BASIC?

You can join Independent Health’s Medicare Anywhere Basic if you are entitled to
Medicare Part A and enrolled in Medicare Part B and live in the service area. However,
individuals with End Stage Renal Disease are generally not eligible to enroll in
Independent Health’s Medicare Anywhere Basic unless they are members of our
organization and have been since their dialysis began.

CAN I CHOOSE MY DOCTORS?
A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare
supplement plan. Your doctor or hospital is not required to agree to accept the plan’s
terms and conditions, and thus may choose not to treat you, with the exception of
emergencies. If your doctor or hospital does not agree to accept our payment terms and
conditions, they may choose not to provide healthcare services to you, except in
emergencies.

DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS?
Independent Health’s Medicare Anywhere Basic does cover both Medicare Part B
prescription drugs and Medicare Part D prescription drugs.

WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN?
Independent Health’s Medicare Anywhere Basic has formed a network of pharmacies.
You must use a network pharmacy to receive plan benefits. We may not pay for your
prescriptions if you use an out-of-network pharmacy, except in certain cases. The
pharmacies in our network can change at any time. You can ask for a current pharmacy
directory or visit us at www.independenthealth.com. Our customer service number is
listed at the end of this introduction.

WHAT IS A PRESCRIPTION DRUG FORMULARY?
Independent Health’s Medicare Anywhere Basic uses a formulary. A formulary is a list
of drugs covered by your plan to meet patient needs. We may periodically add, remove,
or make changes to coverage limitations on certain drugs or change how much you pay
for a drug. If we make any formulary change that limits our members’ ability to fill their
prescriptions, we will notify the affected enrollees before the change is made. We will
send a formulary to you and you can see our complete formulary on our Web site at
www.independenthealth.com.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)     2
                     Introduction to the Summary of Benefits Report
          for INDEPENDENT HEALTH’S MEDICARE ANYWHERE BASIC
                      January 1, 2009 - December 31, 2009
                                     NEW YORK STATE

If you are currently taking a drug that is not on our formulary or subject to additional
requirements or limits, you may be able to get a temporary supply of the drug. You can
contact us to request an exception or switch to an alternative drug listed on our
formulary with your physician’s help. Call us to see if you can get a temporary supply
of the drug or for more details about our drug transition policy.

HOW CAN I GET EXTRA HELP WITH PRESCRIPTION DRUG PLAN COSTS?
If you qualify for extra help with your Medicare prescription drug plan costs, your
premium and costs at the pharmacy will be lower. When you join Independent Health’s
Medicare Anywhere Basic, Medicare will tell us how much extra help you are getting.
Then we will let you know the amount you will pay. If you are not getting this extra
help you can see if you qualify by calling 1-800-MEDICARE (1-800-633-4227), TTY users
should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week.

WHAT ARE MY PROTECTIONS IN THIS PLAN?
All Medicare Advantage Plans agree to stay in the program for a full year at a time.
Each year, the plans decide whether to continue for another year. Even if a Medicare
Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan
decides not to continue, it must send you a letter at least 90 days before your coverage
will end. The letter will explain your options for Medicare coverage in your area.
As a member of Independent Health’s Medicare Anywhere Basic, you have the right to
request a coverage determination, which includes the right to request an exception, the
right to file an appeal if we deny coverage for a prescription drug, and the right to file a
grievance. You have the right to request a coverage determination if you want us to
cover a Part D drug that you believe should be covered. An exception is a type of
coverage determination. You may ask us for an exception if you believe you need a
drug that is not on our list of covered drugs or believe you should get a non-preferred
drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization
rules, such as a limit on the quantity of a drug. If you think you need an exception, you
should contact us before you try to fill your prescription at a pharmacy. Your doctor
must provide a statement to support your exception request. If we deny coverage for
your prescription drug(s), you have the right to appeal and ask us to review our
decision. Finally, you have the right to file a grievance if you have any type of problem
with us or one of our network pharmacies that does not involve coverage for a
prescription drug.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)       3
                     Introduction to the Summary of Benefits Report
          for INDEPENDENT HEALTH’S MEDICARE ANYWHERE BASIC
                      January 1, 2009 - December 31, 2009
                                     NEW YORK STATE


WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM?
A Medication Therapy Management (MTM) Program is a free service we may offer.
You may be invited to participate in a program designed for your specific health and
pharmacy needs. You may decide not to participate but it is recommended that you
take full advantage of this covered service if you are selected. Contact Independent
Health’s Medicare Anywhere Basic for more details.

WHAT TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B?
Some outpatient prescription drugs may be covered under Medicare Part B. These may
include, but are not limited to, the following types of drugs. Contact Independent
Health Medicare Anywhere for more details.


  Some Antigens: If they are prepared by a doctor and administered by a properly
   instructed person (who could be the patient) under doctor supervision.
  Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with
   Medicare.
  Erythropoietin (Epoetin alpha or Epogen®): By injection if you have end-stage
   renal disease (permanent kidney failure requiring either dialysis or
   transplantation) and need this drug to treat anemia.
  Hemophilia Clotting Factors: Self-administered clotting factors if you have
   hemophilia.
  Injectable Drugs: Most injectable drugs administered incident to a physician’s
   service.
  Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant
   patients if the transplant was paid for by Medicare, or paid by a private insurance
   that paid as a primary payer to your Medicare Part A coverage, in a Medicare-
   certified facility.
  Some Oral Cancer Drugs: If the same drug is available in injectable form.
  Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic
   regimen. Inhalation and infusion drugs provided through DME.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)     4
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003



               Please call Independent Health for more information about
                        Independent Health Medicare Anywhere.
                    Visit us at www.independenthealth.com or, call us:
                                  Customer Service Hours:
           Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday,
                            8:00 a.m. - 8:00 p.m. Eastern


    Current members should call toll-free (800)-665-1502 for questions related to the
    Medicare Advantage Program and Medicare Part D Prescription Drug program


  Prospective members should call toll-free (800)-958-4405 for questions related to the
    Medicare Advantage Program and Medicare Part D Prescription Drug program.


    Current members should call locally (716)-250-4401 for questions related to the
    Medicare Advantage Program and Medicare Part D Prescription Drug Program
                           (TTY/TDD (716)-631-3108)


   Prospective members should call locally (716)-635-4900 for questions related to the
    Medicare Advantage Program and Medicare Part D Prescription Drug Program.
                            (TTY/TDD (716)-635-4840)


             For more information about Medicare, please call Medicare at
       1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
                     You can call 24 hours a day, 7 days a week.
                       Or, visit www.medicare.gov on the web.


       If you have special needs, this document may be available in other formats.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)      5
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003

                                                                Independent Health’s
Benefit Category                  Original Medicare
                                                                Medicare Anywhere Basic
IMPORTANT INFORMATION
1 - Premium and Other             In 2008 the monthly Part      General
Important Information             B Premium was $96.40          $35 monthly plan premium in
                                  and will change for 2009      addition to your monthly
                                  and the yearly Part B         Medicare Part B premium.
                                  deductible amount was         The Part B premium will
                                  $135 and will change for      change for 2009.
                                  2009.

                                  If a doctor or supplier
                                  does not accept
                                  assignment, their costs
                                  are often higher, which
                                  means you pay more.

2. Doctor and Hospital            You may go to any             You may have to pay a
Choice                            doctor, specialist or         separate copay for certain
(For more information, see        hospital that accepts         doctor office visits.
Emergency - #15 and               Medicare.                     You may go to any doctor,
Urgently Needed Care -                                          specialist, or hospital that
#16.)                                                           accepts the plan’s payment.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)           6
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003

                                                                  Independent Health’s
Benefit Category                 Original Medicare
                                                                  Medicare Anywhere Basic
SUMMARY OF BENEFITS
INPATIENT CARE
3. Inpatient Hospital Care        In 2008 the amounts for       General
(Includes Substance Abuse         each benefit period were:     You may go to any doctor,
and Rehabilitation Services)      Days 1 - 60: $1,024           specialist, or hospital that
                                  deductible.                   accepts the plan’s Terms &
                                  Days 61 - 90: $256 per        Conditions of payment
                                  day.                          except in emergencies.
                                  Days 91 - 150: $512 per
                                  lifetime reserve day.
                                                                $500 copay for each
                                  These amounts will            Medicare-covered hospital
                                  change for 2009.              stay.
                                  Call 1-800-MEDICARE
                                  (1-800-633-4227) for
                                  information about             $0 copay for additional
                                  lifetime reserve days.        hospital days.
                                  Lifetime reserve days
                                  can only be used once.
                                                                $500 out of pocket limit every
                                  A “benefit period” starts     year.
                                  the day you go into a
                                  hospital or skilled
                                  nursing facility. It ends     No limit to the number of
                                  when you go for 60 days       days covered by the plan
                                  in a row without hospital     each benefit period.
                                  or skilled nursing care. If
                                  you go into the hospital
                                  after one benefit period
                                  has ended, a new benefit
                                  period begins. You must
                                  pay the inpatient
                                  hospital deductible for
                                  each benefit period.
                                  There is no limit to the
                                  number of benefit
                                  periods you can have.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)           7
                            SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
                                                   Independent Health’s
Benefit Category               Original Medicare
                                                   Medicare Anywhere Basic
4. Inpatient Mental Health        Same deductible and           $500 copay for each Medicare
Care                              copay as inpatient            - covered hospital stay.
                                  hospital care (see            The maximum out-of-pocket
                                  “Inpatient Hospital           limit is covered under,
                                  Care” above).                 “Inpatient Hospital Care.”
                                  190 day lifetime limit.       You get up to 190 days in a
                                                                lifetime.
5 - Skilled Nursing Facility      In 2008 the amounts for       $500 copay for each SNF stay.
(in a Medicare-certified          each benefit period after
                                  at least a 3-day covered      $500 out-of-pocket limit
skilled nursing facility)                                       every year.
                                  hospital stay:
                                  Days 1 - 20: $0 per day
                                  Days 21 - 100: $128 per       Plan covers up to 100 days
                                  day                           each benefit period.
                                  These amounts will
                                  change for 2009.
                                                                No prior hospital stay is
                                  100 days for each benefit     required.
                                  period.
                                  A “benefit period” starts
                                  the day you go into a
                                  hospital or skilled
                                  nursing facility. It ends
                                  when you go for 60 days
                                  in a row without hospital
                                  or skilled nursing care. If
                                  you go into the hospital
                                  after one benefit period
                                  has ended, a new benefit
                                  period begins. You must
                                  pay the inpatient
                                  hospital deductible for
                                  each benefit period.
                                  There is no limit to the
                                  number of benefit
                                  periods you can have.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)          8
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003

                                                                Independent Health’s
Benefit Category                  Original Medicare
                                                                Medicare Anywhere Basic
6 - Home Health Care              $0 Copay                      $5 copay for each Medicare-
(includes medically                                             covered home health visit.
necessary intermittent
skilled nursing care, home
health aide services, and
rehabilitation services, etc.)
7 - Hospice                       You pay part of the cost      General
                                  for outpatient drugs and      You must get care from a
                                  inpatient respite care.       Medicare-certified hospice.
                                  You must get care from a
                                  Medicare-certified
                                  hospice.
OUTPATIENT CARE

8 – Doctor Office Visits          20% coinsurance1 2            General
                                                                You may go to any doctor,
                                                                specialist, or hospital that
                                                                accepts the plan’s payment.


                                                                See “Physical Exams,” for
                                                                more information.


                                                                $20 to $35 copay for each
                                                                primary care doctor visit for
                                                                Medicare-covered benefits.


                                                                $35 copay for each specialist
                                                                visit for Medicare-covered
                                                                benefits.
1Each  year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
 If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)            9
                            SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
                                                   Independent Health’s
Benefit Category               Original Medicare
                                                   Medicare Anywhere Basic
9 - Chiropractic Services         Routine care not              $35 copay for Medicare-
                                  covered.                      covered visits.
                                  20% coinsurance for           Medicare-covered
                                  manual manipulation           chiropractic visits are for
                                  of the spine to correct       manual manipulation
                                  subluxation (a                of the spine to correct a
                                  displacement or               displacement or
                                  misalignment of a joint       misalignment of a joint or
                                  or body part) if you get it   body part.
                                  from a chiropractor
                                  or other qualified
                                  provider.1 2
10 – Podiatry Services            Routine care not              $35 copay for each Medicare-
                                  covered.                      covered visit.
                                  20% coinsurance for           Medicare-covered podiatry
                                  medically necessary foot      benefits are for medically-
                                  care, including care for      necessary foot care.
                                  medical conditions
                                  affecting the lower
                                  limbs.1 2
11 – Outpatient Mental            50% coinsurance for           50% of the cost for each
Health Care                       most outpatient mental        Medicare-covered individual
                                  health services.1 2           or group therapy visit.
12 - Outpatient Substance         20% coinsurance1 2            50% of the cost for Medicare-
Abuse Care                                                      covered individual or group
                                                                visits.
13 - Outpatient                   20% coinsurance for the       20% of the cost for each
Services/Surgery                  doctor1 2                     Medicare-covered
                                                                ambulatory surgical center
                                  20% of outpatient
                                                                visit.
                                  facility1 2
                                                                20% of the cost for each
                                                                Medicare-covered outpatient
                                                                hospital facility visit.
1Each  year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
 If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.


H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)          10
                           SUMMARY OF BENEFITS REPORT
                              FOR CONTRACT H9519 PLAN 003
Benefit Category                 Original Medicare   Independent Health’s
                                                     Medicare Anywhere Basic
14 - Ambulance Services           20% coinsurance1 2            $100 copay for Medicare-
(medically necessary                                            covered ambulance benefits
ambulance services)
15 - Emergency Care               20% coinsurance for the       $50 copay for Medicare-
(You may go to any                doctor1 2                     covered emergency room
emergency room if you                                           visits.
                                  20% of facility charge, or
reasonably believe you need       a set copay per               Worldwide coverage.
emergency care.)                  emergency room visit. 1 2     If you are admitted to the
                                  You don’t have to pay         hospital within 24-hour(s) for
                                  the emergency room            the same condition, you pay
                                  copay if you are              $0 for the emergency room
                                  admitted to the hospital      visit.
                                  for the same condition
                                  within 3 days of the
                                  emergency room visit. 1 2
                                  NOT covered outside the
                                  U.S. except under limited
                                  circumstances.
16 - Urgently Needed Care         20% coinsurance, or a set     General
(This is NOT emergency            copay1 2                  Cost sharing is the same as
care, and in most cases, is       NOT covered outside the Doctor Office Visit cost
out of the service area.)         U.S. except under limited sharing.
                                  circumstances.
17 - Outpatient                   20% coinsurance1 2            $35 copay for Medicare-
Rehabilitation Services                                         covered Occupational
(Occupational Therapy,                                          Therapy visits.
Physical Therapy, Speech                                        $35 copay for Medicare-
and Language Therapy)                                           covered Physical and/or
                                                                Speech/Language Therapy
                                                                visits.
1Each  year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
 If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)         11
                           SUMMARY OF BENEFITS REPORT
                               FOR CONTRACT H9519 PLAN 003
Benefit Category                  Original Medicare   Independent Health’s
                                                      Medicare Anywhere Basic
OUTPATIENT MEDICAL SERVICES AND SUPPLIES
18 - Durable Medical              20% coinsurance1 2            20% of the cost for Medicare-
Equipment                                                       covered items.
(includes wheelchairs,
oxygen, etc.)
19 - Prosthetic Devices           20% coinsurance1 2            20% of the cost for Medicare-
(includes braces, artificial                                    covered items.
limbs and eyes, etc.)
20 - Diabetes Self-               20% coinsurance1 2            $35 copay for Diabetes self-
Monitoring Training,                                            monitoring training.
Nutrition Therapy, and         Nutrition therapy is for
Supplies                       people have diabetes or          $35 copay for Nutrition
                               kidney disease (but              Therapy for Diabetes.
(includes coverage for         aren’t on dialysis or
glucose monitors, test strips, haven’t had a kidney             20% of the cost for Diabetes
lancets, screening tests, and transplant) when                  supplies.
self-management training)      referred by a doctor.
                               These services can be
                               given by a registered
                               dietitian or include a
                               nutritional assessment
                               and counseling to help
                               you manage your
                               diabetes or kidney
                               disease.
1Each  year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
 If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)           12
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category               Original Medicare   Independent Health’s
                                                   Medicare Anywhere Basic
21 - Diagnostic Tests,            20% coinsurance for           $0 copay for Medicare-
X-Rays, and Lab Services          diagnostic tests and          covered lab services.
                                  x-rays1 2                     $20 to $35 copay for
                                  $0 copay for Medicare-        Medicare-covered diagnostic
                                  covered lab services1 2       procedures and tests.
                                  Lab Services: Medicare        $35 copay for Medicare-
                                  covers medically              covered X-rays.
                                  necessary diagnostic lab      $35 copays for Medicare-
                                  services that are ordered     covered diagnostic radiology
                                  by your treating doctor       services.
                                  when they are provided
                                  by a Clinical Laboratory      $35 copay for Medicare-
                                  Improvement                   covered therapeutic
                                  Amendments (CLIA)             radiology services.
                                  certified laboratory that
                                  participates in Medicare.
                                  Diagnostic lab services
                                  are done to help your
                                  doctor diagnose or rule
                                  out a suspected illness or
                                  condition. Medicare does
                                  not cover most routine
                                  screening tests, like
                                  checking your
                                  cholesterol.

PREVENTIVE SERVICES

22 - Bone Mass                    20% coinsurance1 2            $0 copay for Medicare-
Measurement                                                     covered bone mass
                                  Covered once every 24
(for people with Medicare                                       measurement
                                  months (more often if
who are at risk)                  medically necessary) if
                                  you meet certain medical
                                  conditions.
1Each  year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
 If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)       13
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category               Original Medicare   Independent Health’s
                                                   Medicare Anywhere Basic
23 - Colorectal Screening         20% coinsurance1 2            $0 copay for Medicare-
Exams                                                           covered colorectal screenings
                                  Covered when you are
(for people with Medicare         high risk or when you
age 50 and older)                 are age 50 and older.
24 – Immunizations                $0 copay for Flu and          $0 copay for Flu and
(Flu vaccine, Hepatitis B         Pneumonia vaccines            Pneumonia vaccines.
vaccine – for people with         20% coinsurance for           $0 copay for Hepatitis B
Medicare who are at risk,         Hepatitis B vaccine. 1 2      vaccine.
Pneumonia vaccine)
                                  You may only need the
                                  Pneumonia vaccine once
                                  in your lifetime. Call
                                  your doctor for more
                                  information.
25 - Mammograms (Annual           20% coinsurance1 2            $0 copay for Medicare-
Screening)                                                      covered screening
                                  No referral needed.
(for women with Medicare                                        mammograms
age 40 and older)                 Covered once a year for
                                  all women with
                                  Medicare aged 40 and
                                  older. One baseline
                                  mammogram covered
                                  for women with
                                  Medicare between age 35
                                  and 39.

26 - Pap Smears and Pelvic        $0 copay for Pap smears2      $0 copay for Medicare-
Exams                                                           covered pap smears and
                                  Covered once every 2
(for women with Medicare)                                       pelvic exams
                                  years. Covered once a
                                  year for women with           $0 copay for additional pap
                                  Medicare at high risk.        smears and pelvic exams
                                  20% coinsurance for           No limit on the number of
                                  Pelvic Exams2                 covered pap smears and
                                                                pelvic exams.
1Each  year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)          14
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category               Original Medicare   Independent Health’s
                                                   Medicare Anywhere Basic
27 - Prostate Cancer              20% coinsurance for the       $0 copay for Medicare-
Screening Exams                   digital rectal exam. 1 2      covered prostate cancer
(for men with Medicare age                                      screening.
                                  $0 for the PSA test;
50 and older)                     20% coinsurance for
                                  other related services. 1 2
                                  Covered once a year for
                                  all men with Medicare
                                  over age 50.
28 – End-Stage Renal              20% coinsurance for           $0 copay for renal dialysis
Disease                           dialysis. 1 2                 $35 copay for Nutrition
                                  20% coinsurance for           Therapy for End-Stage Renal
                                  Nutrition Therapy for         Disease.
                                  End-Stage Renal Disease.
                                  Nutrition therapy is for
                                  people who have
                                  diabetes or kidney
                                  disease (but aren’t on
                                  dialysis or haven’t had a
                                  kidney transplant) when
                                  referred by a doctor.
                                  These services can be
                                  given by a registered
                                  dietitian or include a
                                  nutritional assessment
                                  and counseling to help
                                  you manage your
                                  diabetes or kidney
                                  disease.
1Each  year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)          15
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
                                                                Independent Health’s
Benefit Category                  Original Medicare
                                                                Medicare Anywhere Basic
29 - Prescription Drug            Most drugs not covered        Drugs covered under
                                  under original Medicare.      Medicare Part B
                                  You can add prescription      General
                                  drug coverage to              $20 to $35 copay [or 20% of
                                  Original Medicare by          the cost] for Part B-covered
                                  joining a Medicare            drugs (not including Part B-
                                  Prescription Drug Plan,       covered chemotherapy
                                  or you can get all your       drugs).
                                  Medicare coverage,
                                  including prescription        $0 copay for Part B-covered
                                  drug coverage, by             chemotherapy drugs.
                                  joining a Medicare            Drugs Covered under
                                  Advantage Plan or a           Medicare Part D
                                  Medicare Cost Plan that       General
                                  offers prescription drug
                                                                This plan uses a formulary.
                                  coverage.
                                                                The plan will send you the
                                                                formulary. You can also see
                                                                the formulary at
                                                                www.independenthealth.com
                                                                on the web.
                                                                Different out-of-pocket costs
                                                                may apply for people who
                                                                   have limited incomes,
                                                                   live in long term care
                                                                    facilities, or
                                                                   have access to
                                                                    Indian/Tribal/Urban
                                                                    (Indian Health Service).
                                                                The plan offers national in-
                                                                network prescription
                                                                coverage (i.e., this would
                                                                include 50 states and DC).
                                                                This means that you will pay
                                                                the same cost-sharing
                                                                amount for your prescription
                                                                drugs if you get them at an
                                                                in-network pharmacy outside



H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)           16
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category               Original Medicare   Independent Health’s
                                                   Medicare Anywhere Basic
29 - Prescription Drug                                          of the plan’s service area for
(Continued)                                                     instance when you travel).
                                                                Total yearly drug costs are
                                                                the total drug costs paid by
                                                                both you and the plan.
                                                                The plan may require you to
                                                                first try one drug to treat
                                                                your condition before it will
                                                                cover another drug for that
                                                                condition.
                                                                Some drugs have quantity
                                                                limits.
                                                                Your provider must get prior
                                                                authorization from
                                                                Independent Health’s
                                                                Medicare Anywhere Basic for
                                                                certain drugs.
                                                                The plan will pay for certain
                                                                over-the-counter drugs as
                                                                part of its utilization
                                                                management program. Some
                                                                over-the-counter drugs are
                                                                less expensive than
                                                                prescription drugs and work
                                                                just as well. Contact the plan
                                                                for details.
                                                                You must go to certain
                                                                pharmacies for a very limited
                                                                number of drugs, due to
                                                                special handling, provider
                                                                coordination, or patient
                                                                education requirements for
                                                                these drugs that cannot be
                                                                met by more pharmacies in
                                                                your network. These drugs
                                                                are listed on the plan’s
                                                                website, formulary, and



H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)             17
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category                  Original Medicare             Independent Health’s
                                                                Medicare Anywhere Basic
29 - Prescription Drug                                          printed materials, as well as
(Continued)                                                     on the Medicare Prescription
                                                                Drug Plan Finder on
                                                                Medicare.gov.
                                                                If the actual cost of the drug
                                                                is less than the normal cost-
                                                                sharing amount for that drug,
                                                                you will pay the actual cost,
                                                                not the higher cost-paying
                                                                amount.
                                                                $0 deductible.
                                                                Initial Coverage
                                                                You pay the following until
                                                                total yearly drug costs reach
                                                                $2,700:
                                                                Retail Pharmacy
                                                                Tier 1
                                                                   $5 copay for a one-
                                                                    month (30-day) supply
                                                                    of drugs in this tier
                                                                  $15 copay for a three-
                                                                     month (90-day) supply
                                                                     of drugs in this tier
                                                                Tier 2
                                                                   $35 copay for a one-
                                                                    month (30-day) supply
                                                                    of drugs in this tier
                                                                  $105 copay for a three-
                                                                     month (90-day) supply
                                                                     of drugs in this tier
                                                                Tier 3
                                                                   $70 copay for a one-
                                                                    month (30-day) supply
                                                                    of drugs in this tier




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)            18
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category                  Original Medicare             Independent Health’s
                                                                Medicare Anywhere Basic
29 - Prescription Drug                                            $210 copay for a three-
(Continued)                                                         month (90-day) supply
                                                                    of drugs in this tier
                                                                Specialty Tier 4
                                                                  33% coinsurance for a
                                                                     one-month (30-day)
                                                                     supply of drugs in this
                                                                     tier
                                                                Long Term Care Pharmacy
                                                                Tier 1
                                                                  $5 copay for a one-
                                                                     month (34-day) supply
                                                                     of drugs in this tier
                                                                Tier 2
                                                                  $35 copay for a one-
                                                                     month (34-day) supply
                                                                     of drugs in this tier
                                                                Tier 3
                                                                  $70 copay for a one-
                                                                    month (34-day) supply
                                                                    of drugs
                                                                Specialty Tier 4
                                                                  33% coinsurance for a
                                                                     one-month (34-day)
                                                                     supply of drugs
                                                                Mail Order
                                                                Tier 1
                                                                  $12.50 copay for a three-
                                                                     month (90-day) supply
                                                                     of drugs in this tier
                                                                Tier 2
                                                                   $87.50 copay for a three-
                                                                    month (90-day) supply
                                                                    of drugs in this tier.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)           19
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category                  Original Medicare             Independent Health’s
                                                                Medicare Anywhere Basic
29 - Prescription Drug                                          Coverage Gap
(Continued)                                                     The plan covers Some
                                                                Generics, Some Brands
                                                                through the coverage gap.

                                                                You pay the following:

                                                                Retail Pharmacy
                                                                Tier 1
                                                                   $5 copay for a one-
                                                                    month (30-day) supply
                                                                    of Some Generics, Some
                                                                    Brands drugs covered in
                                                                    this tier
                                                                  $15 copay for a three-
                                                                     month (90-day) supply
                                                                     of Some Generics, Some
                                                                     Brands drugs covered in
                                                                     this tier
                                                                Long Term Care Pharmacy
                                                                Tier 1
                                                                  $5 copay for a one-
                                                                     month (34-day) supply
                                                                     of Some Generics, Some
                                                                     Brands drugs
                                                                Mail Order
                                                                Tier 1
                                                                   $12.50 copay for a three-
                                                                    month (90-day) supply
                                                                    of Some Generics, Some
                                                                    Brands drugs covered in
                                                                    this tier
                                                                Please contact the Plan for a
                                                                complete list of drugs
                                                                covered through the gap.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)            20
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category                  Original Medicare             Independent Health’s
                                                                Medicare Anywhere Basic
29 - Prescription Drug                                          For all other covered drugs,
(Continued)                                                     after your total yearly drug
                                                                costs reach $2,700, you pay
                                                                100% until your yearly out-
                                                                of-pocket drug costs reach
                                                                $4,350.
                                                                Catastrophic Coverage
                                                                After your yearly out-of-
                                                                pocket drug costs reach
                                                                $4,350, you pay the greater
                                                                of:
                                                                   A $ 2.40 copay for
                                                                    generic (including brand
                                                                    drugs treated as generic)
                                                                    and a $6.00 copay for all
                                                                    other drugs, or
                                                                   5% coinsurance.
                                                                Plan drugs may be covered in
                                                                special circumstances, for
                                                                instance, illness while
                                                                traveling outside of the plan’s
                                                                service area where there is no
                                                                network pharmacy. You may
                                                                pay more than your normal
                                                                cost-sharing amount if you
                                                                get your drugs at an out-of-
                                                                network pharmacy. In
                                                                addition, you will likely have
                                                                to pay the pharmacy’s full
                                                                charge for the drug and
                                                                submit documentation to
                                                                receive reimbursement from
                                                                Independent Health
                                                                Medicare Anywhere.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)           21
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category                  Original Medicare             Independent Health’s
                                                                Medicare Anywhere Basic
29 - Prescription Drug                                          Out-of-Network Initial
(Continued)                                                     Coverage
                                                                You will be reimbursed up to
                                                                the full cost of the drug
                                                                minus the following for
                                                                drugs purchased out-of-
                                                                network until total yearly
                                                                drug costs reach $2,700:
                                                                Out-of-Network Pharmacy
                                                                Tier 1
                                                                  $5 copay for a one-
                                                                     month (30-day) supply
                                                                     of drugs in this tier
                                                                Tier 2
                                                                  $35 copay for a one-
                                                                     month (30-day) supply
                                                                     of drugs in this tier
                                                                Tier 3
                                                                  $70 copay for a one-
                                                                    month (30-day) supply
                                                                    of drugs in this tier
                                                                Specialty Tier 4
                                                                   33% coinsurance for a
                                                                    one-month (30-day)
                                                                    supply of drugs in this
                                                                    tier


                                                                Out-of-Network Coverage
                                                                Gap
                                                                The plan covers Some
                                                                Generics, Some Brands
                                                                through the gap.
                                                                You pay the following:




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)          22
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category               Original Medicare   Independent Health’s
                                                   Medicare Anywhere Basic
29 - Prescription Drug                                          Tier 1
(Continued)
                                                                  $5 copay for a one-
                                                                     month (30-day) supply
                                                                     of Some Generics, Some
                                                                     Brands drugs covered in
                                                                     this tier.
                                                                Tier 2
                                                                  After your total yearly
                                                                     drug costs reach $2,700,
                                                                     you pay 100% of the
                                                                     pharmacy’s full charge
                                                                     for drugs purchased
                                                                     out-of-network until
                                                                     your yearly out-of-
                                                                     pocket drug costs reach
                                                                     $4,350. You will not be
                                                                     reimbursed by
                                                                     Independent Health
                                                                     Medicare Anywhere for
                                                                     out-of-network
                                                                     purchases when you are
                                                                     in the coverage gap.
                                                                     However, you should
                                                                     still submit
                                                                     documentation to
                                                                     Independent Health
                                                                     Medicare Anywhere so
                                                                     we can add the amounts
                                                                     you spent out-of-
                                                                     network to your total
                                                                     out-of-pocket costs for
                                                                     the year.
                                                                Tier 3
                                                                   After your total yearly
                                                                    drug costs reach $2,700,
                                                                    you pay 100% of the
                                                                    pharmacy’s full charge
                                                                    for drugs purchased



H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)        23
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category               Original Medicare   Independent Health’s
                                                   Medicare Anywhere Basic
29 - Prescription Drug                                            out-of-network until
(Continued)                                                         your yearly out-of-
                                                                    pocket drug costs reach
                                                                    $4,350. You will not be
                                                                    reimbursed by
                                                                    Independent Health
                                                                    Medicare Anywhere for
                                                                    out-of-network
                                                                    purchases when you are
                                                                    in the coverage gap.
                                                                    However, you should
                                                                    still submit
                                                                    documentation to
                                                                    Independent Health
                                                                    Medicare Anywhere so
                                                                    we can add the amounts
                                                                    you spent out-of-
                                                                    network to your total
                                                                    out-of-pocket costs for
                                                                    the year.
                                                                Specialty Tier 4
                                                                   After your total yearly
                                                                    drug costs reach $2,700,
                                                                    you pay 100% of the
                                                                    pharmacy’s full charge
                                                                    for drugs purchased
                                                                    out-of-network until
                                                                    your yearly out-of-
                                                                    pocket drug costs reach
                                                                    $4,350. You will not be
                                                                    reimbursed by
                                                                    Independent Health
                                                                    Medicare Anywhere for
                                                                    out-of-network
                                                                    purchases when you are
                                                                    in the coverage gap.
                                                                    However, you should
                                                                    still submit
                                                                    documentation to



H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)       24
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category               Original Medicare   Independent Health’s
                                                   Medicare Anywhere Basic
29 - Prescription Drug                                            Independent Health
(Continued)                                                         Medicare Anywhere so
                                                                    we can add the amounts
                                                                    you spent out-of-
                                                                    network to your total
                                                                    out-of-pocket costs for
                                                                    the year.
                                                                Out-of-Network
                                                                Catastrophic Coverage
                                                                  After your yearly out-of-
                                                                  pocket drug costs reach
                                                                  $4,350, you will be
                                                                  reimbursed for drugs
                                                                  purchased out-of-network
                                                                  up to the full cost of the
                                                                  drug minus the following:
                                                                   A $2.40 copay for
                                                                    generic (including brand
                                                                    drugs treated as generic)
                                                                    and a $6.00 copay for all
                                                                    other drugs, or
                                                                   5% coinsurance.
30 - Dental Service               Preventive dental             In general, preventive dental
                                  services (such as             benefits (such as cleaning)
                                  cleaning) not covered.        not covered.
                                                                $35 to $50 copay for
                                                                Medicare-covered dental
                                                                benefits.
                                                                Plan offers additional
                                                                comprehensive dental
                                                                benefits.
1Each  year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)           25
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category               Original Medicare   Independent Health’s
                                                   Medicare Anywhere Basic
31 - Hearing Services             Routine hearing exams         Hearing aids not covered.
                                  and hearing aids not
                                                                   $35 copay for Medicare-
                                  covered.
                                                                    covered diagnostic
                                  20% coinsurance for               hearing exams
                                  diagnostic hearing
                                                                   $35 copay for routine
                                  exams. 1 2
                                                                    hearing tests
                                                                   $35 copay for each
                                                                    fitting-evaluation for
                                                                    hearing aid fitting
                                                                    evaluations
32 - Vision Services              20% coinsurance for             $0 copay for:
                                  diagnosis and treatment
                                                                   one pair of eyeglasses or
                                  of diseases and
                                                                    contact lenses after
                                  conditions of the eye. 1 2
                                                                    cataract surgery.
                                  Routine eye exams and
                                                                   Up to 1 pair(s) of
                                  glasses not covered.
                                                                    contacts
                                  Medicare pays for one
                                                                   Up to 1 pair(s) of lenses
                                  pair of eyeglasses or
                                  contact lenses after             Up to 1 frame(s)
                                  cataract surgery. 1 2            $35 copay for exams to
                                  Annual glaucoma                   diagnose and treat
                                  screenings covered for            diseases and conditions
                                  people at risk. 1 2               of the eye
                                                                   $5 copay for up to 1
                                                                    routine eye exam(s)
                                                                   $60 limit for eye wear.
                                                                Plan offers additional vision
                                                                benefits.
1Each  year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)          26
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category               Original Medicare   Independent Health’s
                                                   Medicare Anywhere Basic
33. Physical Exams                20% coinsurance for one       $0 copay for routine exams.
                                  exam within the first         Limited to 1 exam(s) every
                                  12 months of your new         year.
                                  Medicare Part B
                                  coverage. 1 2
                                  When you get Medicare
                                  Part B, you can get a one
                                  time physical exam
                                  within the first 12
                                  months of your new Part
                                  B coverage. The
                                  coverage does not
                                  include lab tests.
Health Wellness Education         Smoking Cessation:            This plan covers
                                  Covered if ordered by         health/wellness education
                                  your doctor. Includes         benefits.
                                  two counseling attempts          Written health education
                                  within a 12-month                 materials, including
                                  period if you are                 Newsletters
                                  diagnosed with a
                                  smoking-related illness          Nutritional Training
                                  or are taking medicine           Nutritional benefit
                                  that may be affected by
                                                                   Additional Smoking
                                  tobacco. Each counseling
                                                                    Cessation
                                  attempt includes up to
                                  four face-to-face visits.        Health Club
                                  You pay coinsurance,              Membership/Fitness
                                  and Part B deductible             Classes
                                  applies.
                                                                   Nursing Hotline
                                                                Copays may apply for these
                                                                benefits.
                                                                $0 copay for each Medicare-
                                                                covered smoking cessation
                                                                counseling session.
1Each  year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
 If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.



H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)          27
                           SUMMARY OF BENEFITS REPORT
                            FOR CONTRACT H9519 PLAN 003
Benefit Category               Original Medicare   Independent Health’s
                                                   Medicare Anywhere Basic
Transportation                    Not covered.                  This plan does not cover
(Routine)                                                       routine transportation.
Acupuncture                       Not covered.                  This plan does not cover
                                                                Acupuncture.




H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D)       28