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					     MedicareAdvantagePrivate-Fee-For-ServicePlans




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                                                                                                                                                                       ealthCareChoicesforMinnesotansonMedicare
                                                                                                                                   

                                                                 www.AveraAdvantage.com                                www.AveraAdvantage.com
                                                      AveraAdvantageValuePlusH5421-134                   AveraAdvantagePremierPlusH5421-133
                                                                     1-800-999-3947                                       1-800-999-3947
                                                                   TTY: 1-800-888-9680                                  TTY: 1-800-888-9680
                                                               8 a.m.-8 p.m., 7 days a week                         8 a.m.-8 p.m., 7 days a week
     ServiceArea                                Lincoln, Lyon and Pipestone counties in Minnesota.   Lincoln, Lyon and Pipestone counties in Minnesota.

     HospitalInpatient                          $495 co-pay per stay.                                $195 co-pay per stay.

     Physician/Outpatient                        $125 hospital co-pay.                                $75   hospital co-pay.
                                                 $125 ambulatory surgical center co-pay.              $75   ambulatory surgical center co-pay.
                                                 $20 primary care provider co-pay.                    $10   primary care physician co-pay.
                                                 $40 specialist co-pay.                               $25   specialist co-pay.
     EmergencyServices/UrgentCare              $50 co-pay ER; $35 co-pay urgent care.               $50 co-pay ER; $35 co-pay urgent care.

     PreventiveServices                         $0 co-pay.                                           $0 co-pay.

     DiagnosticTests,X-raysandLabServices   0% co-insurance lab and diagnostic procedures;       0% co-insurance lab and diagnostic procedures;
                                                 20% co-insurance radiology.                          20% co-insurance radiology.
     Physical/Speech/OccupationalTherapy        $20 co-pay.                                          $15 co-pay.
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     HomeHealthCare                            20% co-insurance.                                    15% co-insurance.

     MentalHealth                               50% co-insurance.                                    50% co-insurance.

     ChemicalDependency                         50% co-insurance.                                    50% co-insurance.

     SkilledNursingCare                        $100 co-pay days 21-100.                             $100 co-pay days 21-100.




                                                                                                                                                           MedicareAdvantagePrivate-Fee-For-ServicePlans
     DurableMedicalEquipment                   20% co-insurance.                                    20% co-insurance.

     Dental                                      Medicare-covered only.                               Medicare-covered only.

     Chiropractic                                $40 co-pay.                                          $25 co-pay.

     TravelBenefits                             None.                                                None.

     MedicarePartBDrugs                       20% co-insurance.                                    20% co-insurance.

     MedicarePartDOutpatientPrescriptions    Deductible: $0                                       Deductible: $0
                                                 BrandNameDrugs: $35 co-pay.                        BrandNameDrugs: $35 co-pay.
                                                 GenericDrugs: $5 co-pay.                            GenericDrugs: $5 co-pay.
                                                 Non-preferredBrandNameDrugs: $65 co-pay.          Non-preferredBrandNameDrugs: $65 co-pay.
                                                 SpecialtyDrugs: 33% co-insurance.                   SpecialtyDrugs: 33% co-insurance.
                                                 DonutHoleCoverage: Generics only.                  DonutHoleCoverage: Generics only.
                                                 ShinglesVaccine: $65 co-pay.                        ShinglesVaccine: $65 co-pay.
                                                 Mail order is not available.                         Mail order is not available.
                                                 Contact plan for list of participating pharmacies.   Contact plan for list of participating pharmacies.
                                                                                                                                     MedicareAdvantagePrivate-Fee-For-ServicePlans
     Discounts/SpecialPrograms           None.                                      None.

     NumberofProvidersIn-Network       Contact plan for list of providers.        Contact plan for a list of network providers.

     EnrollmentStatus/HealthScreening   Open enrollment.                           Open enrollment.

     MaximumAnnualOut-of-PocketCosts   $3,400                                     $3,250

     MonthlyPremium                      PlanOnly: $27                             PlanOnly: $62
                                          PlanwithPartDPremium: $37              PlanwithPartDPremium: $83




      QuickTip11
      MedicareandOutpatientMentalHealthCoverage
      BeginninginJanuary2010throughDecember2013,MedicarePartBcoverageforoutpatientmentalhealthservices
      willincreasetobeequaltootherMedicarePartBoutpatientservices.

      Year                                                  Medicarecoverage         Youpay




                                                                                                                                                ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
      Before January 1, 2010                                 50 percent                 50 percent
      January 1, 2010–December 31, 2011                      55 percent                 45 percent
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      January 1, 2012–December 31, 2012                      60 percent                 40 percent
      January 1, 2013–December 31, 2013                      65 percent                 35 percent
      January 1, 2014                                        80 percent                 20 percent
     MedicareAdvantagePrivate-Fee-For-ServicePlans




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                                                                                                                                                                                                 ealthCareChoicesforMinnesotansonMedicare
                                                                  www.humana-medicare.com                                           www.humana-medicare.com
                                                            HumanGoldChoiceH2944-02                                        HumanGoldChoiceH2944-03
                                                                       1-800-833-2312                                                    1-800-833-2312
                                                                     TTY: 1-877-833-4486                                               TTY: 1-877-833-4486
                                                                       Monday–Saturday                                                   Monday–Saturday

     ServiceArea                                All 87 Minnesota counties.                                        All 87 Minnesota counties.

     HospitalInpatient                          $225 co-pay per day (days 1-7) per each Medicare-covered          $225 co-pay per day (days 1-7) per each Medicare-covered
                                                 admission.Remaining balance up to the Medicare-allowed           admission. Remaining balance up to the Medicare-allowed
                                                 amount covered in full.No additional co-pay for related          amount covered in full. No additional co-pay for related
                                                 professional or ancillary services while inpatient.              professional or ancillary services while inpatient.
     Physician/Outpatient                        Medicare-covered physician services covered in full,              Medicare-covered physician services covered in full,
                                                 subject to a $15 co-pay (primary care doctor), or                 subject to a $15 co-pay (primary care doctor), or
                                                 $35 co-pay (specialist). Outpatient hospital services,            $35 co-pay (specialist). Outpatient hospital services,
                                                 including laboratory, X-ray and surgical, subject to              including laboratory, X-ray and surgical, subject to
                                                 25% co-insurance. Radiation therapy, chemotherapy                 25% co-insurance. Radiation therapy, chemotherapy
                                                 and renal dialysis subject to 20% co-insurance.                   and renal dialysis subject to 20% co-insurance.
     EmergencyServices/UrgentCare              $50 co-pay for emergency room services. 20% of the cost           $50 co-pay. $100 co-pay for ambulance.
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                                                 for Medicare-covered ambulance benefits.
     PreventiveServices                         One annual routine physical with limited lab and radiology        One annual routine physical with limited lab and radiology
                                                 covered in full after $0 (primary care) co-pay. Medicare-         covered in full after $0 (primary care) co-pay. Medicare-
                                                 approved cancer screenings and immunizations covered in           approved cancer screenings and immunizations covered in
                                                 full when no other services are provided. Routine hearing         full when no other services are provided. Routine hearing
                                                 test every 2 years covered in full after $35 co-pay.              test every 2 years covered in full after $35 co-pay.




                                                                                                                                                                                     MedicareAdvantagePrivate-Fee-For-ServicePlans
     DiagnosticTests,X-raysandLabServices   $15 to $35 co-pay (or 20% to 25% of the cost) for              $0- $125 co-pay for Medicare-covered lab services. $15-
                                                 Medicare-covered diagnostic procedures and tests, X-rays,      $125 co-pay for Medicare-covered diagnostic procedures
                                                 diagnostic radiology and therapeutic radiology. $0 co-pay for and tests, X-rays and diagnostic and therapeutic radiology.
                                                 Medicare-covered lab services in a free-standing lab facility.
     Physical/Speech/OccupationalTherapy        $35 co-pay per visit or 20% to 25% of the cost,                   $35-$125 co-pay per visit per Medicare-covered therapies.
                                                 no maximum or cap.
     HomeHealthCare                            No co-pay for Medicare-covered home health visits and services.   No co-pay for Medicare-covered home health visits and services.

     MentalHealth                               Outpatient: $35 co-pay.                                           Outpatient: $35 co-pay.

     ChemicalDependency                         Outpatient: 25% co-insurance.                                     Outpatient: $125 co-pay.

     SkilledNursingCare                        Days1-14: Covered in full.                                Days1-14: Covered in full.
                                                 Days15-100: $100 co-pay each day. (No three-day inpatient Days15-100: $100 co-pay each day. (No three-day inpatient
                                                 qualification stay required.)                              qualification stay required.)
     DurableMedicalEquipment                   In-network 20% co-insurance for Medicare-covered                  In-network 20% co-insurance for Medicare-covered
                                                 durable medical equipment. Equipment must meet                    durable medical equipment. Equipment must meet
                                                 Medicare medical necessity guidelines.                            Medicare medical necessity guidelines.
                                                                                                                                                                            MedicareAdvantagePrivate-Fee-For-ServicePlans
     Dental                                     Limited to coverage provided under Original Medicare and      Limited to coverage provided under Original Medicare and
                                                subject to a $35 co-pay. Routine dental care not covered.     subject to a $35 co-pay. Routine dental care not covered.
     Chiropractic                               Medicare-covered services. $35 co-pay per visit.              Medicare-covered services. $35 co-pay per visit.

     TravelBenefits                            No provider networks. Enrollees may see any provider          No provider networks. Enrollees may see any provider
                                                willing to accept the terms and conditions of payment         willing to accept the terms and conditions of payment
                                                under the Humana Gold Choice plan. Worldwide travel           under the Humana Gold Choice plan. Worldwide travel
                                                benefit: When outside the U.S. for not more than 60           benefit: When outside the U.S. for not more than 60
                                                consecutive days, emergency and urgently needed services      consecutive days, emergency and urgently needed services
                                                are covered. Co-insurance is 20% of Medicare-covered          are covered. Co-insurance is 20% of Medicare-covered
                                                services, up to a maximum benefit of $25,000 annually         services, up to a maximum benefit of $25,000 annually
                                                with a $250 annual deductible.                                with a $250 annual deductible.
     MedicarePartBDrugs                      20% of the cost for Medicare-covered Part B drugs and for 20% of the cost for Medicare-covered Part B drugs and for
                                                Part B chemotherapy drugs.                                Part B chemotherapy drugs.
     MedicarePartDOutpatientPrescriptions   Deductible: $0                                             Deductible: $0
                                                BrandNameDrugs: $42 co-pay.                              BrandNameDrugs: $42 co-pay.
                                                GenericDrugs: $8 co-pay.                                  GenericDrugs: $8 co-pay.
                                                Non-preferredBrandNameDrugs: $80 co-pay.                Non-preferredBrandNameDrugs: $80 co-pay.
                                                SpecialtyDrugs: 33% co-insurance.                         SpecialtyDrugs: 33% co-insurance.
                                                ShinglesVaccine: Cost share determined by place of        ShinglesVaccine: Cost share determined by place of




                                                                                                                                                                                       ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
                                                treatment (physician office versus pharmacy).              treatment (physician office versus pharmacy).
                                                Mail order is available.                                   Mail order is available.
                                                ExtraServicesandCoverage: $0 co-pay generic. Mail order ExtraServicesandCoverage: $0 co-pay generic. Mail order
                                                through RightSource.                                       through RightSource.
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                                                65,000 participating pharmacies nationwide.                65,000 participating pharmacies nationwide.
     Discounts/SpecialPrograms                 SilverSneakers® Fitness program.Dental, hearing and          SilverSneakers® Fitness program. Dental, hearing and
                                                vision discounts.QuitNet smoking cessation program and       vision discounts. QuitNet smoking cessation program and
                                                Medicare-covered smoking cessation program $15 (primary       Medicare-covered smoking cessation program $15 (primary
                                                care) or $35 (specialist) co-pay. 24 hour nurse hotline.      care) or $35 (specialist) co-pay. 24 hour nurse hotline.
                                                                                                              Chronic condition disease management programs.
     NumberofProvidersIn-Network             This is a non-network plan. Enrollees may use the services    This is a non-network plan. Enrollees may use the services
                                                of any provider eligible to be paid by Medicare and willing   of any provider eligible to be paid by Medicare and willing
                                                to accept the terms and conditions of the Humana Gold         to accept the terms and conditions of the Humana Gold
                                                Choice plan. For information on terms and conditions,         Choice plan. For information on terms and conditions,
                                                contact Humana Gold Choice’s Provider Relations.              contact Humana Gold Choice’s Provider Relations.
     EnrollmentStatus/HealthScreening         Annual open enrollment period, November 15 to December Annual open enrollment period, November 15 to December
                                                31 of each year. End-stage renal disease ineligible.   31 of each year. End-stage renal disease ineligible.
                                                No health screening.                                   No health screening.
     MaximumAnnualOut-of-PocketCosts         $5,000 (Excludes Rx, worldwide coverage, and monthly          $5,000 (Excludes Rx, worldwide coverage, and monthly
                                                premiums).                                                    premiums).
     MonthlyPremium                            $58                                                           $85
     MedicareAdvantagePrivate-Fee-For-ServicePlans




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                                                                                                                                                                                        ealthCareChoicesforMinnesotansonMedicare
                                                               humana-medicare.com                                                www.medica.com
                                                     HumanaGoldChoiceH2944-072                           MedicaAdvantageSolutionSMStandardH2410-001
                                                       1-800-833-2312; 1-800-833-2312                                    952-992-2345; 1-800-906-5432
                                                               TTY: 1-877-833-4486                              TTY: 1-800-855-2880 and ask for 1-800-906-5432
                                                                 Monday-Saturday                                        8 a.m. to 8 p.m. CST, 7 days a week

     ServiceArea                           All 87 Minnesota counties.                                       Select counties in Minnesota and North Dakota.

     HospitalInpatient                     $225 co-pay per day (days 1-7) per each Medicare-covered         $550 for each Medicare-covered hospital stay.You pay
                                            admission.Remaining balance up to the Medicare-allowed          nothing for additional hospital stays.
                                            amount covered in full.No additional co-pay for related
                                            professional or ancillary services while inpatient.
     Physician/Outpatient                   Medicare-covered physician services covered in full,         You pay $15 co-pay for each primary care doctor visit for
                                            subject to a$15 co-pay. (primary care doctor), or $35       Medicare-covered services. You pay $30 co-pay for each
                                            co-pay (specialist).Outpatient hospital services, including specialist visit for Medicare-covered services.
                                            laboratory, X-ray and surgical,subject to 25% co-insurance.
                                            Radiation therapy, chemotherapy andrenal dialysis subject
                                            to 20% co-insurance.
     EmergencyServices/UrgentCare         $50 co-pay for emergency room services.                         $50 co-pay for each Medicare-covered emergency room visit.
                                            20% co-insurance of the cost for Medicare-covered                Worldwide emergency coverage when traveling outside the U.S.
76




                                            ambulance benefits.                                              a $50 co-pay applies. $15 to $30 co-pay or 20% co-insurance
                                                                                                             for the cost of each Medicare-covered urgent care services.
     PreventiveServices                    One annual routine physical with limited lab and radiology     One covered annual preventive exam per year.No co-pay for
                                            covered infull after $0 (primary care) co-pay. Medicare-      colorectal cancer screening, immunizations, mammograms,
                                            approved cancerscreenings and immunizations covered in        pap smears, pelvic exams or prostate cancer screening.
                                            full when no other servicesare provided. Routine hearing test
                                            every 2 years covered in full after$35 co-pay.




                                                                                                                                                                            MedicareAdvantagePrivate-Fee-For-ServicePlans
     DiagnosticTests,X-raysandLab      $0 to $35 co-pay (or 25% of the cost) for Medicare-covered      You pay $15 to $30 co-pay (or 20% of the cost) for
                                            diagnostic procedures and tests, X-rays, diagnostic radiology   Medicare-covered services depending on where services
     Services                               and therapeutic radiology. $0 co-pay for Medicare-covered        are received.
                                            labservices in a free-standing lab facility.
     Physical/Speech/OccupationalTherapy   $35 co-pay per visit or 20% to 25% of the cost,                  $30 co-pay for each Medicare-covered PT/OT/ST visit.
                                            no maximum or cap.

     HomeHealthCare                       No co-pay for Medicare-covered home health visits and services. No co-pay for Medicare-covered home health visits.

     MentalHealth                          Outpatient: $35 co-pay.                                          Outpatient: $30 co-pay for each Medicare-covered
                                                                                                             individual or group therapy visit.
                                                                                                             Inpatient: You pay $550 co-pay for each Medicare-covered
                                                                                                             hospital stay.
     ChemicalDependency                    Outpatient: 25% co-insurance.                                    $30 co-pay for each Medicare-covered individual/group visit.

     SkilledNursingCare                   Days1-7: Covered in full.                                       Days1-20: $0 co-pay each day.
                                            Days8-100: $84 co-pay per day.(No three-day inpatient          Days21-100: $120 co-pay each day.
                                            hospital stay is required).                                      No three-day hospital stay is required.
                                                                                                             Coverage is for 100 days each benefit period.
     DurableMedicalEquipment                  In-network: 20% co-insurance for Medicare-covered durable You pay 25% co-insurance for each Medicare-covered item.




                                                                                                                                                                                    MedicareAdvantagePrivate-Fee-For-ServicePlans
                                                medical equipment. Equipment must meet Medicare medical
                                                necessity guidelines.
     Dental                                     Limited to coverage provided under original Medicare and           You pay 100% for preventative dental services.You pay $30
                                                subject to a$35 co-pay. Routine dental care not covered.          co-pay for Medicare-covered dental services.
     Chiropractic                               Medicare-covered services. $35 co-pay per visit.                   $30 co-pay for each Medicare-covered visit (manual
                                                                                                                   manipulation of spine to correct a displacement or
                                                                                                                   misalignment of a joint or body part).
     TravelBenefits                            No provider networks. Enrollees may see any provider willing to   This plan does not contract with a provider network. You may
                                                accept the terms and conditions of payment under the Humana        seeany Medicare doctor, specialist or hospital that accepts
                                                GoldChoice plan. Worldwide travel benefit: When outside the       Medicare payment and accepts terms, conditions and
                                                U.S.for not more than 60 consecutive days, emergency and          payment rate of Medica Health Plans. Worldwide emergency
                                                urgentlyneeded services are provided. Co-insurance is 20%         coverage when traveling outside the U.S. A $50 co-pay
                                                of Medicare-coveredservices, up to a maximum benefit of           applies for emergency services.
                                                $25,000 annually with a$250 annual deductible.
     MedicarePartBDrugs                      20% of the cost for Medicare-covered Part B drugs and for          20% co-insurance for Part B drugs.
                                                Part B chemotherapy drugs.
     MedicarePartDOutpatientPrescriptions Deductible: $310                                                      Medicare Part D outpatient prescriptions are not covered with
                                                BrandNameDrugs: 25% co-insurance after deductible.                this plan.
                                                GenericDrugs: 25% co-insurance after deductible.




                                                                                                                                                                                               ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
                                                Non-preferredBrandNameDrugs: 25% co-insurance after
                                                deductible.
                                                SpecialtyDrugs: 25% co-insurance after deductible.
                                                ShinglesVaccine: Cost share determined by place of treatment
77




                                                (physician office versus pharmacy).
                                                ExtraServicesandCoverage: Contact plan.Mail order is available.
                                                65,000 participating pharmacies available nationwide.
     Discounts/SpecialPrograms                 SilverSneakers® Fitness program.Dental, hearing and vision        You pay 100% for hearing aids. You pay $30 for each
                                                discounts.QuitNet smoking cessation program and Medicare-         Medicare-covered hearing exam (diagnostic hearing exams).
                                                covered smoking cessation program $15 co-pay (primary              You pay $30 for each routine hearing test up to one test
                                                care) or $35 co-pay (specialist). 24 hour nurse hotline.           every year.
     NumberofProvidersIn-Network             This is a non-network plan. Enrollees may use the services         This plan does not contract with a provider network. You may
                                                of anyprovider eligible to be paid by Medicare and willing        see any Medicare doctor, specialist or hospital that accepts
                                                to accept the termsand conditions of the Humana Gold              Medicare payment and accepts terms, conditions and
                                                Choice plan. For information onterms and conditions contact       payment rate of Medica Health Plans.
                                                Humana Gold Choice’s Provider Relations.
     EnrollmentStatus/HealthScreening         Annual open enrollment period, November 15 to                      Enrollment open. New enrollees with end-stage renal disease
                                                December 31 ofeach year. End-stage renal disease                  are not eligible. No health screening.
                                                ineligible. No health screening.
     MaximumAnnualOut-of-PocketCosts         $5,000 (Excludes Rx, worldwide coverage, and monthly               $3,350
                                                premiums).
     MonthlyPremiums                           $164                                                               $9
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                             H
                                                                                                                                                                                              ealthCareChoicesforMinnesotansonMedicare
                                                                                                                                               
                                                                                                                                              
                                                                                                                                              
                                                                      www.medica.com                                                  www.medica.com
                                                            MedicaAdvantageSolution          SM
                                                                                                                            MedicaAdvantageSolutionSM
                                                             StandardwithRxH2410-015                                         ChoiceH2410-009
                                                             952-992-2345; 1-800-906-5432                                   952-992-2345; 1-800-906-5432
                                                    TTY: 1-800-855-2880 and ask for 1-800-906-5432                 TTY: 1-800-855-2880 and ask for 1-800-906-5432
                                                            8 a.m. to 8 p.m. CST, 7 days a week                            8 a.m. to 8 p.m. CST, 7 days a week

     ServiceArea                                Select counties in Minnesota and North Dakota.                 Select counties in Minnesota and North Dakota.

     HospitalInpatient                          $550 for each Medicare-covered hospital stay.                 Days1-60: $1,100 deductible.
                                                 You pay nothing for additional hospital stays.                 Days61-90: $275 co-pay each day.
                                                                                                                Days91-150: $550 co-pay per lifetime reserve day.
                                                                                                                Coverage is for 90 days each benefit period.
     Physician/Outpatient                        You pay $15 for each primary care doctor visit for Medicare-   You pay 20% co-insurance for primary care doctor visit for
                                                 covered services. You pay $30 for each specialist visit for    Medicare-covered benefits.You pay 20% co-insurance for each
                                                 Medicare-covered services.                                     specialist visit for Medicare-covered services.You pay 20%
                                                                                                                co-insurance for each Medicare-covered visit in an ambulatory
                                                                                                                surgical center or in an outpatient hospital facility.
     EmergencyServices/UrgentCare              $50 co-pay for each Medicare-covered emergency room visit.     You pay 20% co-insurance up to $50 for each Medicare-covered
78




                                                 Worldwide emergency coverage when traveling outside the U.S.   emergency room visit (not covered outside the U.S. except under
                                                 a $50 co-pay applies. $15 to $30 co-pay or 20% co-insurance    limited circumstances).You pay 20% co-insurance for each
                                                 for the cost of each Medicare-covered urgent care services.    in-area, network Medicare-covered urgent care visit.
     PreventiveServices                         One covered annual preventive exam per year.No co-pay for     20% co-insurance for an annual routine health assessment,
                                                 colorectal cancer screening, immunizations, mammograms,        annual routine eyeand hearing exams, routine mammograms
                                                 pap smears, pelvic exams or prostate cancer screening.         and pap smears, routinecancer tests and screenings.




                                                                                                                                                                                  MedicareAdvantagePrivate-Fee-For-ServicePlans
                                                                                                                There is no co-pay for flu and pneumonia vaccines.
     DiagnosticTests,X-raysandLabServices   You pay $15 to $30 co-pay (or 20% of the cost) for Medicare-   You pay 20% co-insurance for Medicare-covered services.
                                                 covered services depending on where services are received.
     Physical/Speech/OccupationalTherapy        $30 co-pay for each Medicare-covered PT/OT/ST visit.           You pay 20% co-insurance for each Medicare-covered
                                                                                                                PT/OT/ST visit.
     HomeHealthCare                            There is no co-pay for Medicare-covered home health visits.    You pay $0 co-pay for Medicare-covered home health visits.

     MentalHealth                               Outpatient: $30 co-pay for each Medicare-covered individual You pay 50% co-insurance for each individual or group
                                                 or group therapy visit.                                    visit for Medicare-covered benefits.
                                                 Inpatient: You pay $550 co-pay for each Medicare-covered
                                                 hospital stay.
     ChemicalDependency                         $30 co-pay for each Medicare-covered individual/group visits. Outpatient: You pay 20% co-insurance for each individual or
                                                                                                               group visit for Medicare-covered benefits.
     SkilledNursingCare                        Days1-20: $0 co-pay per day.                                 Days1-20: $0 co-pay per day.
                                                 Days21-100: $120 co-pay per day.                             Days21-100: $137.50 co-pay per day.
                                                 No prior hospital stay is required.                           Three-day prior hospital stay required.
                                                 Coverage is for 100 days each benefit period.                  You are covered for 100 days each benefit period.
                                                                                                                                                                                      MedicareAdvantagePrivate-Fee-For-ServicePlans
     DurableMedicalEquipment                  You pay 25% co-insurance of the cost for each Medicare-            You pay 20% co-insurance of the cost for Medicare-covered items
                                                covered item.                                                      and supplies.
     Dental                                     You pay 100% for preventive dental services.You pay               You must go to network providers. In general, you pay
                                                $30 co-pay for Medicare-covered dental services.                   100% for non-Medicare-covered dental services. You pay
                                                                                                                   20% co-insurance of Medicare-covered dental services.
     Chiropractic                               $30 co-pay for each Medicare-covered visit (manual                 You pay 20% co-insurance for Medicare-covered benefits
                                                manipulation of spine to correct a displacement or                 (manual manipulation of the spine to correct displacement or
                                                misalignment of a joint or body part).                             misalignment of a joint or body part).
     TravelBenefits                            This plan does not contract with a provider network. You may       This plan does not contract with a provider network. You may
                                                seeany Medicare doctor, specialist or hospital that accepts       see any Medicare doctor, specialist or hospital that accepts
                                                Medicare payment and accepts terms, conditions and                 Medicare payment and accepts terms, conditions and payment
                                                payment rate of Medica Health Plans. Worldwide emergency           rate of Medica Health Plans.
                                                coverage when traveling outside the U.S. A $50 co-pay
                                                applies for emergency services.
     MedicarePartBDrugs                      20% co-insurance for Part B drugs.                                 After $155 deductible, you pay 20% co-insurance for
                                                                                                                   Medicare-eligible Part B medications.
     MedicarePartDOutpatientPrescriptions   Deductible: $0                                                     Deductible: $310
                                                BrandNameDrugs: $34 co-pay.                                      BrandNameDrugs:25% co-insurance.




                                                                                                                                                                                                 ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
                                                GenericDrugs: $10 co-pay.                                         GenericDrugs:25% co-insurance.
                                                Non-preferredBrandNameDrugs: $74 co-pay.                        Non-preferredBrandNameandSpecialtyDrugs:25% co-
                                                SpecialtyDrugs: 25% co-insurance.                                 insurance.
                                                ShinglesVaccine: Tier 2 co-payment; call plan.                    ShinglesVaccine: 25% co-insurance.
79




                                                ExtraServicesandCoverage: Medication Therapy                    ExtraServicesandCoverage: Medication Therapy
                                                Management available.                                             Management available.
                                                Mail order is available.                                           Mail order is available.
                                                Over 1,400 network pharmacies.Please check website for details.   Over 1,400 network pharmacies.Please check website for details.
     Discounts/SpecialPrograms                 You pay 100% for hearing aids. You pay $30 co-pay for each        Written health education materials, including newsletters;
                                                Medicare-covered hearing exam (diagnostic hearing exams). You additional smoking cessation; health club membership/fitness
                                                pay $30 co-pay for each routine hearing test up to one test every classes; nursing hotline.
                                                year.
     NumberofProvidersIn-Network             This plan does not contract with a provider network. You may This is a non-network plan. See the plan for specifics.
                                                see any Medicare doctor, specialist or hospital that accepts
                                                Medicare payment and accepts terms, conditions and
                                                payment rate of Medica Health Plans.
     EnrollmentStatus/HealthScreening         Enrollment open. New enrollees with end-stage renal disease        Enrollment open. New enrollees with end-stage renal disease
                                                are not eligible. No health screening.                             are not eligible. No health screening.
     MaximumAnnualOut-of-PocketCosts         $3,350                                                             N/A

     MonthlyPremiums                           $0                                                                 $29.10
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                           H
                                                                                                                                                                                            ealthCareChoicesforMinnesotansonMedicare
                                                                   www.sterlingplans.com                                           www.sterlingplans.com
                                                         SterlingBasicPlus     SM
                                                                                     H5006-018                              SterlingOptionI®H5006-014
                                                 1-888-858-8544 (Enrollment); 1-888-858-8572 (Sales)             1-888-858-8544 (Enrollment); 1-888-858-8572 (Sales)
                                                                TTY: 1-888-858-8567                                             TTY: 1-888-858-8567
                                                           5 a.m.-8 p.m. PST, 7 days a week                                5 a.m.-8 p.m. PST, 7 days a week
     ServiceArea                                Segment1: Anoka, Carver, Chisago, Dakota, Hennepin,           Segment1: Anoka, Carver, Chisago, Dakota, Hennepin, Isanti,
                                                 Isanti, Ramsey, Scott, Sherburne, Washington, Wright           Ramsey, Scott, Sherburne, Washington, Wright counties.
                                                 counties. Segment2: Aitkin, Becker, Beltrami, Benton,         Segment2: Aitkin, Becker, Beltrami, Benton, Big Stone,
                                                 Big Stone, Blue Earth, Brown, Carlton, Cass, Chippewa,         Blue Earth, Brown, Carlton, Cass, Chippewa, Clay, Clearwater,
                                                 Clay, Clearwater, Cook, Cottonwood, Crow Wing, Dodge,          Cook, Cottonwood, Crow Wing, Dodge, Douglas, Faribault,
                                                 Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant,        Fillmore, Freeborn, Goodhue, Grant, Houston, Hubbard,
                                                 Houston, Hubbard, Itasca, Jackson, Kanabec, Kandiyohi,         Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Koochiching,
                                                 Kittson, Koochiching, Lac qui Parle, Lake of the Woods,        Lac qui Parle, Lake of the Woods, Le Sueur, Lincoln, Lyon,
                                                 Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin,           Mahnomen, Marshall, Martin, McLeod, Meeker, Mille
                                                 McLeod, Meeker, Mille Lacs, Morrison, Mower, Murray,           Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman,
                                                 Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington,     Olmsted, Otter Tail, Pennington, Pine, Pipestone, Polk, Pope,
                                                 Pine, Pipestone, Polk, Pope, Red Lake, Redwood, Renville,      Red Lake, Redwood, Renville, Rice, Rock, Roseau, Sibley,
                                                 Rice, Rock, Roseau, Sibley, St Louis, Stearns, Steele,         St Louis, Stearns, Steele, Stevens, Swift, Todd, Traverse,
                                                 Stevens, Swift, Todd, Traverse, Wabasha, Wadena, Waseca,       Wabasha, Wadena, Waseca, Watonwan, Wilkin, Winona,
                                                 Watonwan, Wilkin, Winona, Yellow Medicine counties.            Yellow Medicine counties.
80




     HospitalInpatient                          Hospital Inpatient: $200 co-pay for each day(s) up to 5        Hospital Inpatient: $150 co-pay for each day(s) up to 5
                                                 days. Benefit for unlimited days. Hospice: Only Sterling       days. Benefit for unlimited days; Hospice: Only Sterling
                                                 added benefits (non-Medicare) are covered during hospice       added benefits (non-Medicare) are covered during hospice
                                                 election period.                                               election period.
     Physician/Outpatient                        Primary care doctor office visit: $20 co-pay; Specialist       Primary care doctor office visit: $20 co-pay; Specialist
                                                 doctor office visit: $40 co-pay; Medicare-covered podiatry     doctor office visit: $40 co-pay; Medicare-covered podiatry
                                                 care: $40 co-pay (Member pays cost of non-Medicare-            care: $40 co-pay (Member pays cost of non-Medicare-




                                                                                                                                                                                MedicareAdvantagePrivate-Fee-For-ServicePlans
                                                 covered services).                                             covered services).
     EmergencyServices/UrgentCare              Medically necessary ambulance trips: $100 co-pay for           Medically necessary ambulance trips: $100 co-pay for each
                                                 each Medicare-covered trip (enrollee pays cost for miles       Medicare-covered trip (enrollee pays cost for miles beyond
                                                 beyond nearest facility capable of providing services);        nearest facility capable of providing services); Emergency
                                                 Emergency room care: $50 co-pay (waived if admitted            room care: $50 co-pay (waived if admitted within 24 hours
                                                 within 24 hours for the same condition); Urgently needed       for the same condition); Urgently needed care: $20 or $40
                                                 care: $20 or $40 co-pay depends on specialty.                  co-pay depends on specialty.
     PreventiveServices                         No cost-share for the following services: bone mass            No cost-share for the following services: bone mass
                                                 measurement, colorectal cancer screening exams for             measurement, colorectal cancer screening exams for
                                                 those age 50 and older, screening mammogram, yearly            those age 50 and older, screening mammogram, yearly
                                                 screening mammograms, pap smear and pelvic exam for all        screening mammograms, pap smear and pelvic exam for all
                                                 women every 2 years, yearly pap smear for women at high        women every 2 years, yearly pap smear for women at high
                                                 risk, screening exams for prostate cancer, cardiovascular      risk, screening exams for prostate cancer, cardiovascular
                                                 screening blood tests, immunizations, Welcome to Medicare      screening blood tests, immunizations, Welcome to Medicare
                                                 Preventive Physical in first 12 months of Part B coverage.     Preventive Physical in first 12 months of Part B coverage.
     DiagnosticTests,X-raysandLabServices   Medicare-covered laboratory services, diagnostic procedures    Medicare-covered laboratory services, diagnostic procedures
                                                 and tests-no cost-share; Medicare-covered X-rays, diagnostic   and tests-no cost-share; Medicare-covered X-rays, diagnostic
                                                 radiology procedures and therapeutic radiology services-       radiology procedures and therapeutic radiology services-
                                                 15% co-insurance.                                              10% co-insurance.
     Physical/Speech/OccupationalTherapy        Outpatient rehab services: 15% co-insurance.                   Outpatient rehab services: 10% co-insurance.
                                                                                                                                                                                  MedicareAdvantagePrivate-Fee-For-ServicePlans
     HomeHealthCare                           No co-insurance.                                                  No co-insurance.

     MentalHealth                              Inpatientcareinafreestandingpsychiatricclinic:              Inpatientcareinafreestandingpsychiatricclinic:
                                                $200 co-pay for each day(s) up to 5 days coverage for a           $150 co-pay for each day(s) up to 5 days coverage for a
                                                total of 190 days in a lifetime. Part B covers some services      total of 190 days in a lifetime. Part B covers some services
                                                after lifetime max.                                               after lifetime max.
                                                Outpatient: 50% co-insurance.                                     Outpatient: 50% co-insurance.
     ChemicalDependency                        Outpatient: 50% co-insurance.                                     Outpatient: 50% co-insurance.

     SkilledNursingCare                       Day1-10: $0 co-pay.                                              Day1-10: $0 co-pay.
                                                Day11-100: $50 co-pay per day.                                   Day11-100: $50 co-pay per day.
     DurableMedicalEquipment                  20% co-insurance (recommend pre-notification for a                20% co-insurance (recommend pre-notification for a purchase
                                                purchase over $750).                                              over $750).
     Dental                                     Medicare-covered dental: $0 co-pay for Medicare-covered           Medicare-covered dental: $0 co-pay for Medicare-covered
                                                office visit and 15% co-insurance for Medicare-covered            office visit and 10% co-insurance for Medicare-covered
                                                outpatient services in a facility. Preventive dental-oral exam,   outpatient services in a facility. Preventive dental-oral
                                                cleaning, fluoride and X-rays-covered up to $200 a year           exams, cleanings, fluoride and X-rays covered up to $300
                                                (member pays amount over the $200).                               (member pays amount over the $300).
     Chiropractic                               Chiropractic care for manual manipulation of the spine            Chiropractic care for manual manipulation of the spine to
                                                to correct acute subluxation only: $20 co-pay (cost of            correct acute subluxation only: $20 co-pay (cost of
                                                non-Medicare-covered services including routine care are          non-Medicare-covered services including routine care are
                                                member responsibility).                                           member responsibility).




                                                                                                                                                                                             ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
     TravelBenefits                            Worldwide urgent care for first 60 days per trip (only            Worldwide urgent care for first 60 days per trip (only
                                                Medicare-covered services): Yearly, within first 60 days of       Medicare-covered services): Yearly, within first 60 days of
                                                travel: $150 deductible, then 15% co-insurance of billed          travel: $100 deductible, then 10% co-insurance of billed
                                                charges to $25,000.                                               charges to $25,000.
     MedicarePartBDrugs                      20% co-insurance for Medicare-covered services (including         20% co-insurance for Medicare-covered services (including
81




                                                chemotherapy drugs).                                              chemotherapy drugs).
     MedicarePartDOutpatientPrescriptions   Part D coverage is not included with this plan.                   Part D coverage is not included with this plan.

     Discounts/SpecialPrograms                 SilverandFit® program provides free health club                   SilverandFit® program provides free health club
                                                memberships at participating facilities or choice of at-home      memberships at participating facilities or choice of at-home
                                                fitness kits.                                                     fitness kits.
     NumberofProvidersIn-Network             No network restrictions. Your doctor or hospital is not           No network restrictions. Your doctor or hospital is not
                                                required to agree to accept the plan’s terms and conditions,      required to agree to accept the plan’s terms and conditions,
                                                and thus may choose not to treat you, with the exception          and thus may choose not to treat you, with the exception
                                                of emergencies. If your doctor or hospital does not agree         of emergencies. If your doctor or hospital does not agree
                                                to accept our payment terms and conditions, they may              to accept our payment terms and conditions, they may
                                                choose not to provide health care services to you, except         choose not to provide health care services to you, except
                                                in emergencies. Providers can find the plan’s terms and           in emergencies. Providers can find the plan’s terms and
                                                conditions on website at: www.sterlingplans.com.                  conditions on website at: www.sterlingplans.com.
     EnrollmentStatus/HealthScreening         Enrollment open, except end-stage renal disease not eligible.     Enrollment open, except end-stage renal disease not eligible.
                                                No health screening.                                              No health screening required.

     MaximumAnnualOut-of-PocketCosts         $5,000                                                            None.

     MonthlyPremiums                           Segment1:$39                                                    Segment1:$59
                                                Segment2:$59                                                    Segment2:$94
                                                Please refer to service area list to determine your segment       Please refer to service area list to determine your segment
                                                by county.                                                        by county.
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                            H
                                                                                                                                                                             ealthCareChoicesforMinnesotansonMedicare
                                                                                                                     QuickTip12
                                                                   www.sterlingplans.com                             TheMinnesotaBoardonAging,with
                                                           SterlingOptionII®H5006-017                            assistancefromtheMinnesotaLegal
                                                 1-888-858-8544 (Enrollment); 1-888-858-8572 (Sales)                 ServicesCoalition,producedthe
                                                                TTY: 1-888-858-8567                                  guidePlanning Ahead: Who will make
                                                           5 a.m.-8 p.m. PST, 7 days a week                          decisions for you?Planning Aheadcovers
     ServiceArea                           Segment1:Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey,
                                            Scott, Sherburne, Washington, Wright counties. Segment2: Aitkin,        • Informalarrangements
                                            Becker, Beltrami, Benton, Big Stone, Blue Earth, Brown, Carlton, Cass,
                                            Chippewa, Clay, Clearwater, Cook, Cottonwood, Crow Wing, Dodge,          • Formalarrangements
                                            Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Houston,         • Legalplanningtools
                                            Hubbard, Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Koochiching,
                                            Lac qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon,         • Powerofattorney
                                            Mahnomen, Marshall, Martin, McLeod, Meeker, Mille Lacs, Morrison,
                                            Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail,            • Trusts
                                            Pennington, Pine, Pipestone, Polk, Pope, Red Lake, Redwood, Renville,
                                            Rice, Rock, Roseau, Sibley, St Louis, Stearns, Steele, Stevens, Swift,      G
                                                                                                                     •  uardianshipsandconservatorships
                                            Todd, Traverse, Wabasha, Wadena, Waseca, Watonwan, Wilkin, Winona,       • Healthcaredirectives
                                            Yellow Medicine counties.
                                                                                                                     • Healthcareoptions
     HospitalInpatient                     Hospital inpatient: $150 co-pay for each day(s) up to 5 days.
                                            Benefit for unlimited days. Hospice: Only Sterling added benefits        • Funeralplanning
82




                                            (non-Medicare) are covered during hospice election period.
                                                                                                                     • Organandtissuedonation
     Physician/Outpatient                   Primary care doctor office visit: $20 co-pay; Specialist doctor
                                            office visit: $40 co-pay; Medicare-covered podiatry care:                • Wills
                                            $40 co-pay (member pays cost of non-Medicare-covered services).
                                                                                                                     Youcandownloadandprint
     EmergencyServices/UrgentCare         Medically necessary ambulance trips: $150 co-pay for each
                                                                                                                     acopyofPlanning Aheadby
                                            Medicare-covered trip (enrollee pays cost for miles beyond nearest
                                            facility capable of providing services); Emergency room care:




                                                                                                                                                                 MedicareAdvantagePrivate-Fee-For-ServicePlans
                                                                                                                     visitingwww.mnaging.org/pdf/
                                            $50 co-pay (waived if admitted within 24 hours for the same
                                            condition); Urgently needed care: $20 or $40 co-pay (depends on          PlanningAheadBooklet_2009.pdf
                                            specialty).
     PreventiveServices                    No cost-share for the following services: bone mass measurement,
                                            colorectal cancer screening exams for those age 50 and older,
                                            screening mammogram, yearly screening mammograms, pap
                                            smear and pelvic exam for all women every 2 years, yearly pap
                                            smear for women at high risk, screening exams for prostate cancer,
                                            cardiovascular screening blood tests, immunizations, Welcome to
                                            Medicare Preventive Physical in first 12 months of Part B coverage.

     DiagnosticTests,X-raysandLab      Medicare-covered laboratory services, diagnostic procedures and
                                            tests-no cost-share; Medicare-covered X-rays, diagnostic radiology
     Services                               procedures and therapeutic radiology services-15% co-insurance.

     Physical/Speech/OccupationalTherapy   Outpatient rehab services: 15% co-insurance.

     HomeHealthCare                       No co-insurance.
                                                                                                                     MedicareAdvantagePrivate-Fee-For-ServicePlans
     MentalHealth                             Inpatientcareinafreestandingpsychiatricclinic: $150 co-pay
                                               for each day(s) up to 5 days coverage for a total of 190 days in a
                                               lifetime. Part B covers some services after lifetime max.
                                               Outpatient: 50% co-insurance.


     ChemicalDependency                       Outpatient: 50% co-insurance.

     SkilledNursingCare                      Day1-10: $0 co-pay.
                                               Days11-100: $50 co-pay per day.
     DurableMedicalEquipment                 20% co-insurance (recommend pre-notification for a purchase
                                               over $750).
     Dental                                    Medicare-covered dental: $0 co-pay for Medicare-covered office
                                               visit and 15% co-insurance for Medicare-covered outpatient
                                               services in a facility. Preventive dental (1 each) exam, cleaning,
                                               fluoride and X-rays-covered up to $100 a year (member pays
                                               amount over the $100).
     Chiropractic                              Chiropractic care for manual manipulation of the spine to correct
                                               acute subluxation only: $20 co-pay (cost of non-Medicare-covered
                                               services including routine care are member responsibility).

     TravelBenefits                           Worldwide urgent care for first 60 days per trip (only Medicare-
                                               covered services): Yearly, within first 60 days of travel: $150
                                               deductible, then co-insurance of 15% of billed charges to




                                                                                                                                ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
                                               $25,000.
     MedicarePartBDrugs                     20% co-insurance for Medicare-covered services (including
                                               chemotherapy drugs).
83




     MedicarePartDOutpatientPrescriptions Deductible: $225
                                               BrandNameDrugs: $34co-pay.
                                               GenericDrugs: $10 co-pay.
                                               SpecialtyDrugs: 25% co-insurance.
                                               ShinglesVaccine: Partial coverage.Cost varies.
                                               Mail order is available.See pharmacy locator at
                                               www.sterlingplanspharmacy.com/pharmacy.php.
     Discounts/SpecialPrograms                SilverandFit® program provides free health club memberships at
                                               participating facilities or choice of at-home fitness kits.
     NumberofProvidersIn-Network            No network restrictions. 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 health care services to
                                               you, except in emergencies. Providers can find the plan’s terms
                                               and conditions on website at: www.sterlingplans.com.
     EnrollmentStatus/HealthScreening        Enrollment open, except end-stage renal disease not eligible.
                                               No health screening for enrollment.
     MaximumAnnualOut-of-PocketCosts        None.

     MonthlyPremiums                          Segment1: $99
                                               Segment2:$107
                                               Please refer to service area list to determine your segment
                                               by county.
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                     H
                                                                                                                                                                                      ealthCareChoicesforMinnesotansonMedicare
                                                                                                                                             QuickTip13
                                                                                  www.sterlingplans.com                                      IfyouhaveMedicarePart
                                                                                                                                            Dandarenotenrolledin
                                                                          SterlingOptionIV®H5006-016
                                                              1-888-858-8544 (Enrollment); 1-888-858-8572 (Sales)                            MedicalAssistance,you
                                                                                1-888-858-8567                                               shouldconsiderapplying
                                                                        5 a.m.-8 p.m. PST, 7 days a week                                     fortheExtraHelp,also
     ServiceArea                                Segment1: Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott,                 knownasLowIncome
                                                 Sherburne, Washington, Wright counties.Segment2: Aitkin, Becker, Beltrami,                Subsidy(LIS)tohelpyou
                                                 Benton, Big Stone, Blue Earth, Brown, Carlton, Cass, Chippewa, Clay, Clearwater,            payforyourMedicare
                                                 Cook, Cottonwood, Crow Wing, Dodge, Douglas, Faribault, Fillmore, Freeborn,                 PartDplancosts.
                                                 Goodhue, Grant, Houston, Hubbard, Itasca, Jackson, Kanabec, Kandiyohi, Kittson,
                                                                                                                                             Thereisnoriskorcost
                                                 Koochiching, Lac qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon,
                                                 Mahnomen, Marshall, Martin, McLeod, Meeker, Mille Lacs, Morrison, Mower, Murray,            toapply.Contactthe
                                                 Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Pipestone, Polk,           SeniorLinkAgeLine®
                                                 Pope, Red Lake, Redwood, Renville, Rice, Rock, Roseau, Sibley, St Louis, Stearns,           at1-800-333-2433
                                                 Steele, Stevens, Swift, Todd, Traverse, Wabasha, Wadena, Waseca, Watonwan, Wilkin,          formoreinformationor
                                                 Winona, Yellow Medicine counties.                                                           youcanapplyonlineat
     HospitalInpatient                          Hospital inpatient: $150 co-pay for each day(s) up to 5 days. Benefit for unlimited         secure.ssa.gov/apps6z/
                                                 days. Hospice: Only Sterling added benefits (non-Medicare) are covered during
84




                                                                                                                                             i1020/main.html
                                                 hospice election period.
     Physician/Outpatient                        Primary care doctor office visit: $20 co-pay; Specialist doctor office visit: $40 co-pay;
                                                 Medicare-covered podiatry care: $40 co-pay (member pays cost of non-Medicare-
                                                 covered services).
     EmergencyServices/UrgentCare              Medically necessary ambulance trips: $150 co-pay for each Medicare-covered trip
                                                 (enrollee pays cost for miles beyond nearest facility capable of providing services);




                                                                                                                                                                          MedicareAdvantagePrivate-Fee-For-ServicePlans
                                                 Emergency room care: $50 co-pay (waived if admitted within 24 hours for the same
                                                 condition); Urgently needed care: $20 co-pay or $40 co-pay (depends on specialty).
     PreventiveServices                         No cost-share for the following services: bone mass measurement, colorectal
                                                 cancer screening exams for those age 50 and older, screening mammogram,
                                                 yearly screening mammograms, pap smear and pelvic exam for all women every
                                                 2 years, yearly pap smear for women at high risk, screening exams for prostate
                                                 cancer, cardiovascular screening blood tests, immunizations, Welcome to Medicare
                                                 Preventive Physical in first 12 months of Part B coverage.
     DiagnosticTests,X-raysandLabServices   Medicare-covered laboratory services, diagnostic procedures and tests-no cost-
                                                 share; Medicare-covered X-rays, diagnostic radiology procedures and therapeutic
                                                 radiology services-15% co-insurance.
     Physical/Speech/OccupationalTherapy        Outpatient rehab services: 15% co-insurance.

     HomeHealthCare                            No co-insurance.

     MentalHealth                               Inpatientcareinafreestandingpsychiatricclinic: $150 co-pay for each day(s) up to
                                                 5 days coverage for a total of 190 days in a lifetime. After lifetime maximum, Part B
                                                 covers; Outpatient: 50% co-insurance.
     ChemicalDependency                       Outpatient: 50% co-insurance.




                                                                                                                                          MedicareAdvantagePrivate-Fee-For-ServicePlans
     SkilledNursingCare                      Day1-10: $0 co-pay.
                                               Days11-100: $50 co-pay per day.
     DurableMedicalEquipment                 20% co-insurance (recommend pre-notification for a purchase over $750).

     Dental                                    Medicare-covered dental: $0 co-pay for Medicare-covered office visit and 15%
                                               co-insurance for Medicare-covered outpatient services in a facility. Preventive
                                               dental-oral exam, cleaning, fluoride and X-rays-$400 benefit for dental/hearing/
                                               vision combined (member pays amount over the $400 for dental/vision/hearing
                                               combined).
     Chiropractic                              Chiropractic care for manual manipulation of the spine to correct acute
                                               subluxation only: $20 co-pay (cost of non-Medicare-covered services including
                                               routine care are member responsibility).
     TravelBenefits                           Worldwide urgent care for first 60 days per trip (only Medicare-covered services):
                                               Yearly, within first 60 days of travel: $150 deductible, then 15% co-insurance of
                                               billed charges to $25,000.
     MedicarePartBDrugs                     20% co-insurance for Medicare-covered services (including chemotherapy drugs).

     MedicarePartDOutpatientPrescriptions Deductible: $225
                                               BrandNameDrugs: $36 co-pay.
                                               GenericDrugs: $10 co-pay.




                                                                                                                                                     ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
                                               SpecialtyDrugs: 25% co-insurance.
                                               ShinglesVaccine: Partial coverage.
                                               Mail order is available.
                                               See pharmacy locator at www.sterlingplanspharmacy.com/pharmacy.php.
85




     Discounts/SpecialPrograms                Silver & Fit® program provides free health club memberships at participating
                                               facilities or choice of at-home fitness kits. E-mail consults (e-consults) and phone
                                               consults: $24 per e-mail or phone call. Limit $240 per year for both e-mail and
                                               phone calls combined. Health risk assessments: Providers reimbursed $100
                                               per member per year for sending a health risk assessment to Sterling (only one
                                               provider per member). Medical records attestation: Providers reimbursed $50 per
                                               member per year for attestation that they keep medical records electronically (only
                                               one provider per member).
     NumberofProvidersIn-Network            No network restrictions. 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 health care services
                                               to you, except in emergencies. Providers can find the plan’s terms and conditions
                                               on website at: www.sterlingplans.com.
     EnrollmentStatus/HealthScreening        Enrollment open, except end-stage renal disease not eligible.
                                               No health screening required.
     MaximumAnnualOut-of-PocketCosts        $4,000

     MonthlyPremiums                          Segment1: $119
                                               Segment2: $120 (Please refer to service area list to determine your segment by county.)
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                         H
                                                                                                                                                                                          ealthCareChoicesforMinnesotansonMedicare
                                                             www.SecureHorizons.com                                           www.SecureHorizons.com
                                                   SecureHorizonsMedicareDirectRx                                   SecureHorizonsMedicare
                                                           Plan1 H5435-0001                                             DirectRxPlanH5435-014-0
                                                       1-800-555-5757; 1-800-555-5757                                   1-800-555-5757; 1-800-555-5757
                                                             TTY: 1-800-387-1074                                              TTY: 1-800-387-1074
                                                          8 a.m.-8 p.m., 7 days a week                                     8 a.m.-8 p.m., 7 days a week

     ServiceArea                           Becker, Big Stone, Blue Earth, Brown, Carlton, Chippewa,         Becker, Big Stone, Blue Earth, Brown, Carlton, Chippewa,
                                            Clay, Clearwater, Cottonwood, Douglas, Faribault, Fillmore,      Clay, Clearwater, Cottonwood, Douglas, Faribault, Fillmore,
                                            Freeborn, Grant, Houston, Jackson, Kandiyohi, Kittson, Le        Freeborn, Grant, Houston, Jackson, Kandiyohi, Kittson, Le
                                            Sueur, Lincoln, Lyon, Martin, Meeker, Morrison, Nicollet,        Sueur, Lincoln, Lyon, Martin, Meeker, Morrison, Nicollet,
                                            Nobles, Otter Tail, Pennington, Pope, Red Lake, Redwood,         Nobles, Otter Tail, Pennington, Pope, Red Lake, Redwood,
                                            Rice, Rock, Roseau, Sherburne, Stearns, Steele, Swift,           Rice, Rock, Roseau, Sherburne, Stearns, Steele, Swift,
                                            Todd, Traverse, Wabasha, Wadena, Waseca, Washington,             Todd, Traverse, Wabasha, Wadena, Waseca, Washington,
                                            Watonwan, Wilkin and Winona counties in Minnesota.               Watonwan, Wilkin and Winona counties in Minnesota.

     HospitalInpatient                     Days1-7: $225 co-pay per day.                                   Days1-7: $250 co-pay per day.
                                            Days8-90: $0 co-pay per day.                                    Days8-90: $0 co-pay per day.
     Physician/Outpatient                   $15 co-pay primary care; $30 co-pay specialist; 20%              $15 co-pay primary care, $30 co-pay specialist, 20%
86




                                            co-insurance of the cost for each Medicare-covered               co-insurance of the cost for each Medicare-covered
                                            ambulatory surgical center visit.20% of the cost for each       ambulatory surgical center visit. 20% co-insurance of the cost
                                            Medicare-covered outpatient hospital facility visit.             for each Medicare-covered outpatient hospital facility visit.

     EmergencyServices/UrgentCare         $50 co-pay for Medicare-covered emergency room visits.           $50 co-pay for Medicare-covered emergency room visits.
                                            Worldwide coverage. If you are admitted to the hospital          Worldwide coverage.If you are admitted to the hospital
                                            within 24 hours for the same condition, you pay $0 for the       within 24 hours for the same condition, you pay $0 for the




                                                                                                                                                                              MedicareAdvantagePrivate-Fee-For-ServicePlans
                                            emergency room visit.                                            emergency room visit.
     PreventiveServices                    $0 co-pay for bone mass measurement, colorectal cancer           $0 co-pay for immunizations, mammograms (annual
                                            screening exams, immunizations, mammograms (annual               screening), pap smears and pelvic exams, prostate cancer
                                            screening), pap smears and pelvic exams, prostate cancer         screening exams, physical exams, smoking cessation,
                                            screening exams, physical exams, smoking cessation,              one routine physical per year and one pair of eyeglasses or
                                            1 routine physical per year, one pair of eyeglasses or contact   contact lenses after cataract surgery.$30 co-pay for exams
                                            lenses after cataract surgery.$30 co-pay for exams to           to diagnose and treat disease and conditions of the eye.
                                            diagnose and treat diseases and conditions of the eye.          $30 co-pay for up to one routine eye exam every year.
                                            $30 co-pay for up to one routine eye exam every year.


     DiagnosticTests,X-raysandLab      $10 co-pay for Medicare-covered lab services. $0 to $10          $10 co-pay for Medicare-covered lab services.$0 to $10
     Services                               co-pay for Medicare-covered diagnostic procedures and            co-pay for Medicare-covered diagnostic procedures and
                                            tests.$16 co-pay for Medicare-covered X-rays.                   tests. $16 co-pay for Medicare-covered X-rays.
                                            20% for the cost for Medicare-covered diagnostic radiology       20% co-insurance for the cost for Medicare-covered
                                            services. 20% co-insurance for the cost for Medicare-            diagnostic radiology services.20% co-insurance for the
                                            covered therapeutic radiology services.                          cost for Medicare-covered therapeutic radiology services.
     Physical/Speech/OccupationalTherapy   $30 co-pay for Medicare-covered physical/speech/                 $30 co-pay for Medicare-covered physical/speech/
                                            language/occupational therapy visits.                            language/occupational therapy visits.
                                                                                                                                                                               MedicareAdvantagePrivate-Fee-For-ServicePlans
     HomeHealthCare                           $0 co-pay for each Medicare-covered home health visit.       $0 co-pay for each Medicare-covered home health visit.

     MentalHealth                              $40 co-pay for Medicare-covered individual visits.          $40 co-pay for each Medicare-covered individual therapy visit.
                                                $30 co-pay for Medicare-covered group visits.                $30 co-pay for each Medicare-covered group therapy visit.
     ChemicalDependency                        $40 co-pay for Medicare-covered individual visits.          $40 co-pay for Medicare-covered individual visits.
                                                $30 co-pay for Medicare-covered group visits.                $30 co-pay for Medicare-covered group visits.
     SkilledNursingCare                       Day1-30: $95 co-pay per day.                               Days1-26: $110 co-pay per day.
                                                Day31-100:$0 co-pay per day.                               Day27-100: $0 co-pay per day.
                                                No three-day hospital stay required.                        No three-day hospital stay is required.
     DurableMedicalEquipment                  20% co-insurance for the cost of Medicare-covered items.     20% co-insurance for the cost of Medicare-covered items.

     Dental                                     In general, preventive dental benefits (such as cleaning)    In general, preventive dental benefits (such as cleaning)
                                                are not covered.$30 co-pay for Medicare-covered dental      are not covered.$30 co-pay for Medicare-covered dental
                                                benefits.                                                    benefits.
     Chiropractic                               $30 co-pay for each Medicare-covered visit.Medicare-        $30 co-pay for each Medicare-covered visit.Medicare-
                                                covered chiropractic visits are for manual manipulation      covered chiropractic visits are for manual manipulation
                                                of the spine to correct subluxation (a displacement or       of the spine to correct subluxation (a displacement or
                                                misalignment of a joint or body part) if you get it from a   misalignment of a joint or body part) if you get it from a
                                                chiropractor or other qualified providers.                   chiropractor or other qualified providers.
     TravelBenefits                            Worldwide emergency coverage.                                Worldwide emergency coverage.




                                                                                                                                                                                          ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
     MedicarePartBDrugs                      20% of the cost for Part B-covered chemotherapy drugs        20% of the cost for Part B-covered chemotherapy drugs and
                                                and other Part B-covered drugs.                              other Part B-covered drugs.
     MedicarePartDOutpatientPrescriptions No Part D coverage.                                            Deductible:$0
87




                                                                                                             BrandNameDrugs: $42 co-pay.
                                                                                                             GenericDrugs: $6-$116 co-pay.
                                                                                                             Non-preferredBrandNameDrugs: $80-$230 co-pay.
                                                                                                             SpecialtyDrugs: 33% co-insurance.
                                                                                                             ShinglesVaccine: Covered at cost-sharing above.
                                                                                                             Mail order is available.
     Discounts/SpecialPrograms                 None.                                                        None.

     NumberofProvidersIn-Network             No network of providers.                                     No network of providers.

     EnrollmentStatus/HealthScreening         Open enrollment. No health screening during open enrollment. Open enrollment.No health screening during open enrollment.

     MaximumAnnualOut-of-PocketCosts         $4,250                                                       $4,600 in-network.

     MonthlyPremiums                           $0                                                           $20
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                    H
                                                                                                                                                                                     ealthCareChoicesforMinnesotansonMedicare
                                                          www.unicare.com/medicare                                        www.unicare.com/medicare
                           
                                            UnicareSecurityChoiceClassicH0540-001                          UniCareSecurityChoicePlusH0540-020
                                                              1-888-949-5384                                                   1-888-949-5384
                                                           TTY: 1-800-241-6894                                              TTY: 1-800-241-6894
                                                      8 a.m. to 8 p.m. ( 7 days a week)                                8 a.m. to 8 p.m. ( 7 days a week)
     ServiceArea                        Becker, Beltrami, Big Stone, Blue Earth, Brown, Carlton,        Becker, Beltrami, Big Stone, Blue Earth, Brown, Carlton,
                                         Carver, Chippewa, Clay, Clearwater, Cook, Cottonwood,           Carver, Chippewa, Clay, Clearwater, Cook, Cottonwood,
                                         Crow Wing, Dakota, Dodge, Douglas, Fillmore, Freeborn,          Crow Wing, Dakota, Dodge, Douglas, Fillmore, Freeborn,
                                         Goodhue, Grant, Houston, Hubbard, Isanti, Jackson,              Goodhue, Grant, Houston, Hubbard, Isanti, Jackson,
                                         Kandiyohi, Kittson, Lac qui Parle, Lake, Lake of the Woods,     Kandiyohi, Kittson, Lac qui Parle, Lake, Lake of the Woods,
                                         Lincoln, Lyon, Mahnomen, Martin, Morrison, Mower,               Lincoln, Lyon, Mahnomen, Martin, Morrison, Mower, Murray,
                                         Murray, Nobles, Norman, Olmsted, Otter Tail, Pennington,        Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine,
                                         Pine, Pipestone, Polk, Ramsey, Red Lake, Redwood, Rice,         Pipestone, Polk, Ramsey, Red Lake, Redwood, Rice, Rock,
                                         Rock, St. Louis, Stearns, Steele, Swift, Todd, Traverse,        St Louis, Stearns, Steele, Swift, Todd, Traverse, Wabasha,
                                         Wabasha, Waseca, Washington, Watonwan, Wilkin, Winona           Waseca, Washington, Watonwan, Wilkin, Winona and Yellow
                                         and Yellow Medicine counties in Minnesota.                      Medicine counties in Minnesota.

     HospitalInpatient                  For a Medicare-covered stay at a hospital, you pay:            For a Medicare-covered stay at a hospital, you pay:
                                         Days1-6: $280 co-pay each day.                                 Days1-6: $280 co-pay each day.
88




                                         Days7-90: $0 co-pay each day$1,680 maximum out-               Days7-90: $0 co-pay each day$1,680 maximum out-
                                         of-pocket limit per year. There is no co-pay for additional     of-pocket limit per year. There is no co-pay for additional
                                         Medicare-covered days received at a hospital and you are        Medicare-covered days received at a hospital and you are
                                         covered for unlimited days each benefit period.                 covered for unlimited days each benefit period.
     Physician/Outpatient                $25 co-pay for each primary care doctor office visit for        $25 co-pay for each primary care doctor office visit for
                                         Medicare-covered services; $35 co-pay for each specialist       Medicare-covered services; $35 co-pay for each specialist
                                         visit for Medicare-covered service; Medicare-covered            visit for Medicare-covered service; Medicare-covered




                                                                                                                                                                         MedicareAdvantagePrivate-Fee-For-ServicePlans
                                         ambulatory surgical center visits: $35 to $200 co-pay;          ambulatory surgical center visits: $35 to $200 co-pay;
                                         outpatient hospital facility visit: $35 to $250 co-pay.         outpatient hospital facility visit: $35 to $250 co-pay.

     EmergencyServices/UrgentCare      $50 co-pay for each Medicare-covered emergency room visit $50 co-pay for each Medicare-covered emergency room visit
                                         (waived if admitted to the hospital). Worldwide coverage.      (waived if admitted to the hospital). Worldwide coverage.
                                         Urgent care: Cost sharing is the same as doctor office visits. Urgent care: Cost sharing is the same as doctor office visits.
     PreventiveServices                 One annual physical exam covered for $0 co-pay.                 One annual physical exam covered for $0 co-pay.
                                         $0 co-pay for Medicare-covered bone mass measurement,           $0 co-pay for Medicare-covered bone mass measurement,
                                         colorectal screenings, flu, pneumonia and Hepatitis B           colorectal screenings, flu, pneumonia and Hepatitis B
                                         vaccines, screening mammograms, pap smears, pelvic              vaccines, screening mammograms, pap smears, pelvic
                                         exams, prostate cancer screening. One routine hearing           exams, prostate cancer screening. One routine hearing
                                         exam every year covered for a $35 co-pay. Annual routine        exam every year covered for a $35 co-pay. Annual routine
                                         eye exam covered with $35 co-pay.                               eye exam covered with $35 co-pay.
     DiagnosticTests,X-raysandLab   $35 co-pay for Medicare-covered lab services.                   $35 co-pay for Medicare-covered lab services.
                                         $75 to $125 co-pay for Medicare-covered diagnostic              $75 to $125 co-pay for Medicare-covered diagnostic
     Services                            procedures, tests, x-rays, diagnostic radiology services.       procedures, tests, X-rays, diagnostic radiology services.
                                         20% co-insurance of the cost for Medicare-covered               20% co-insurance of the cost for Medicare-covered
                                         therapeutic radiology services.                                 therapeutic radiology services.
                                                                                                                                                                                  MedicareAdvantagePrivate-Fee-For-ServicePlans
     Physical/Speech/OccupationalTherapy          $35-$50 co-pay for each Medicare-covered occupational        $35-$50 co-pay for each Medicare-covered occupational
                                                   therapy visit. $35 -$50 co-pay for each physical and/or      therapy visit.$35 -$50 co-pay for each physical and/or speech
                                                   speech therapy visit.                                        therapy visit.
     HomeHealthCare                              $0 co-pay for Medicare-covered home health visits.           $0 co-pay for Medicare-covered home health visits.

     MentalHealth                                 Outpatient: $40 copay.                                      Outpatient: 50% co-insurance.
                                                   Inpatient: $280 co-pay per stay days 1-6.(190-day           Inpatient: $275 co-pay per stay days 1-5. $1,375 out-of-
                                                   lifetime limit.)                                             pocketyearly limit. (190-day lifetime limit.)
     ChemicalDependency                           $40 co-pay for Medicare-covered individual/group visit.      $30 co-pay for Medicare-covered individual/group visit.

     SkilledNursingCare                          Days1-20: $0 co-pay each day.                              Days1-20: $0 co-pay each day.
                                                   Days21-100: $130 co-pay each day.                           Days21-100: $130 co-pay each day.
                                                   No prior hospital stay is required.                          No prior hospital stay is required.
                                                   Coverage is for 100 days each benefit period.                Coverage is for 100 days each benefit period.
     DurableMedicalEquipment                     You pay 20% co-insurance of the cost for Medicare-           You pay 20% co-insurance of the cost for Medicare-covered
                                                   covered equipment.                                           equipment.
     Dental                                        You pay 100% for routine dental services.                    You pay 100% for routine dental services.

     Chiropractic                                  $35 co-pay for each Medicare-covered visit (manual           $35 co-pay for each Medicare-covered visit (manual
                                                   manipulation of spine to correct subluxation).               manipulation of spine to correct subluxation).
     TravelBenefits                               This plan does not contract with a provider network.         This plan does not contract with a provider network.




                                                                                                                                                                                             ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
                                                   You may see any licensed physician who can provide           You may see anylicensed physician who can provide services
                                                   services to Medicare beneficiaries and who is willing to     to Medicare beneficiariesand who is willing to accept the
                                                   accept the terms and conditions of the plan. Worldwide       terms and conditions of the plan. Worldwide emergency
                                                   emergency room coverage when traveling outside the U.S.      room coverage when traveling outside theU.S. A $50 co-pay
                                                   A $50 co-pay applies.                                        applies (waived if admitted to the hospital within72 hours for
89




                                                                                                                the same condition.)
     MedicarePartBDrugs                         20% co-insurance for the cost for Part B-covered drugs.      20% co-insurance for the cost for Part B-covered drugs.
                                                                                                                $5,000 out-of-pocket limit on Part B drugs.
     MedicarePartDOutpatientPrescriptions This plan does not offer prescription drug coverage.              Deductible: $0
                                                                                                                BrandNameDrugs: $44 co-pay.
                                                                                                                GenericDrugs: $8 co-pay.
                                                                                                                Non-preferredBrandNameDrugs: $85 co-pay.
                                                                                                                SpecialtyDrugs: 33% co-insurance.
                                                                                                                DonutHoleCoverage: Many generics at $8 co-pay.
                                                                                                                Mail order is available.
                                                                                                                Contact plan for a list of participating pharmacies.
     Discounts/SpecialPrograms                    None.                                                        None.

     NumberofProvidersinNetwork                This plan does not contract with a provider network. You     This plan does not contract with a provider network. You
                                                   may see any licensed physician who can provide services      may see anylicensed physician who can provide services to
                                                   to Medicare beneficiaries and who is willing to accept the   Medicare beneficiariesand who is willing to accept the terms
                                                   terms and conditions of the plan.                            and conditions of the plan.

     EnrollmentStatus/HealthScreening            Open enrollment.                                             Enrollment open during annual open enrollment period,
                                                                                                                November15 to December 31 of each year. End-stage renal
                                                                                                                disease not eligible. No health screening required.
     MaximumAnnualOut-of-PocketCosts            $5,000                                                       $5,000 out-of-pocket limit applies to all Medicare-covered
                                                                                                                services.
     MonthlyPremiums                              $0                                                           $23
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                            H
                                                                                                                                                                             ealthCareChoicesforMinnesotansonMedicare
                                                                                                                   QuickTip14
                                                                                                                   TheMinnesotaBoardonAgingis
                                                                  www.unicare.com/medicare                         thegatewaytoservicesforMinnesota
                           
                                                                                                                   seniorsandtheirfamilies.TheMinnesota
                                                      UniCareSecurityChoicePlusH0540-089
                                                                      1-888-949-5384                               BoardonAgingensuresthatolder
                                                                    TTY: 1-800-241-6894                            Minnesotansandtheirfamiliesare
                                                                 8 a.m.-8 p.m., 7 days a week                      effectivelyservedbythestateandlocal
     ServiceArea                                Aitkin, Benton, Cass, Faribault, Itasca, Kanabec,                 policiesandprogramsinordertoagewell
                                                 Koochiching, Le Sueur, Marshall, McLeod, Meeker,                  andlivewell.Visitwww.mnaging.orgfor
                                                 Nicollet, Pope, Renville, Roseau, Scott, Sherburne, Sibley,       moreinformationabouttheMinnesota
                                                 Wadena and Wright counties in Minnesota.
                                                                                                                   BoardonAging.
     HospitalInpatient                          For a Medicare-covered stay at a hospital, you pay:
                                                 Days1-6: $280 co-pay each day.
                                                 Days7-90: $0 co-pay each day$1,680 maximum out-
                                                 of-pocket limit per year. There is no co-pay for additional
                                                 Medicare-covered days received at a hospital and you are
                                                 covered for unlimited days each benefit period.
     Physician/Outpatient                        $25 co-pay for each primary care doctor office visit for
                                                 Medicare-covered services; $35 co-pay for each specialist
90




                                                 visit for Medicare-covered service; Medicare-covered
                                                 ambulatory surgical center visits: $35-$200 co-pay;
                                                 outpatient hospital facility visit: $35 to $200 co-pay.
     EmergencyServices/UrgentCare              $50 co-pay for each Medicare-covered emergency room visit
                                                 (waived if admitted to the hospital). Worldwide coverage.
                                                 Urgentcare: Cost sharing is the same as doctor office visits.




                                                                                                                                                                 MedicareAdvantagePrivate-Fee-For-ServicePlans
     PreventiveServices                         One annual physical exam covered for $0 co-pay.
                                                 $0 co-pay for Medicare-covered bone mass measurement,
                                                 colorectal screenings, flu, pneumonia and Hepatitis B
                                                 vaccines, screening mammograms, pap smears, pelvic
                                                 exams, prostate cancer screening. One routine hearing
                                                 exam every year covered for a $35 co-pay. Annual routine
                                                 eye exam covered with $35 co-pay.
     DiagnosticTests,X-raysandLabServices   $35 co-pay for Medicare-covered lab services. $75 to $125
                                                 co-pay for Medicare-covered diagnostic procedures, tests,
                                                 X-rays, diagnostic radiology services. 20% co-insurance for the
                                                 cost for Medicare-covered therapeutic radiology services.
     Physical/Speech/OccupationalTherapy        $35 to $50 co-pay for each Medicare-covered service.

     HomeHealthCare                            $0 co-pay for Medicare-covered home health visits.

     MentalHealth                               Outpatient: $40 co-pay.
                                                 Inpatient: $280 co-pay per stay days 1-6. $1,680
                                                 out-of-pocket yearly limit.(190-day lifetime limit).
     ChemicalDependency                         $40 co-pay for Medicare-covered individual/group visit.
                                                                                                                                                          MedicareAdvantagePrivate-Fee-For-ServicePlans
     SkilledNursingCare                      Days1-20: $0 co-pay each day.
                                               Days21-100: $130 co-pay each day.
                                               No prior hospital stay is required.
     DurableMedicalEquipment                 You pay 20% of the cost for Medicare-covered equipment.

     Dental                                    You pay 100% for routine dental services.
                                                                                                            QuickTip15
                                                                                                            Becomeacertifiedvolunteerwiththe
     Chiropractic                              $35 co-pay for each Medicare-covered visit (manual
                                               manipulation of spine to correct subluxation).               SeniorLinkAgeLine®tohelpothers
                                                                                                            understandMedicareandlong-termcare
     TravelBenefits                           This plan does not contract with a provider network. You
                                               may see anylicensed physician who can provide services      options.Volunteersareneededinall87
                                               to Medicare beneficiariesand who is willing to accept the   countiesofMinnesota.Completetraining,
                                               terms and conditions of the plan. Worldwide emergency        mentoringandcertificationprovidedatno
                                               room coverage when traveling outside theU.S. A $50 co-      costtoyou.CalltheSeniorLinkAgeLine®
                                               pay applies.
                                                                                                            at1-800-333-2433togetinvolved!
     MedicarePartBDrugs                     20% of the cost for Part B-covered drugs.

     MedicarePartDOutpatientPrescriptions Deductible:$0
                                               BrandNameDrugs: $44 co-pay.
                                               GenericDrugs: $8 co-pay.
                                               Non-preferredBrandNameDrugs: $85 co-pay.




                                                                                                                                                                     ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
                                               SpecialtyDrugs: 33% co-insurance.
                                               DonutHoleCoverage: Many generics at $8 co-pay.
                                               Mail order is available.
                                               Contact plan for a list of participating pharmacies.
91




     Discounts/SpecialPrograms                None.

     NumberofProvidersIn-Network            This plan does not contract with a provider network. You
                                               may see anylicensed physician who can provide services
                                               to Medicare beneficiariesand who is willing to accept the
                                               terms and conditions of the plan.
     EnrollmentStatus/HealthScreening        Enrollment open during annual open enrollment period,
                                               November15 to December 31 of each year. End-stage
                                               renal disease not eligible. No health screening required.
     MaximumAnnualOut-of-PocketCosts        $5,000 out-of-pocket limit applies to all Medicare-covered
                                               services.
     MonthlyPremiums                          $55
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                         H
                                                                                                                                                                                          ealthCareChoicesforMinnesotansonMedicare
                                                 www.Universal-American-Medicare.com      www.Universal-American-Medicare.com       www.Universal-American-Medicare.com
                                                Today’sOptionsValueH5421-165 Today’sOptionsValueH5421-173                    Today’sOptionsValueH5421-181
                                                            1-800-996-8867                           1-800-996-8867                           1-800-996-8867
                                                          TTY: 1-800-777-9083                      TTY: 1-800-777-9083                      TTY: 1-800-777-9083
                                                              8 a.m. to 8 p.m.                         8 a.m. to 8 p.m.                         8 a.m. to 8 p.m.
                                                      in your local time zone everyday         in your local time zone everyday         in your local time zone everyday
     ServiceArea                                Becker, Beltrami, Benton, Big Stone,     Carver, Chisago, Crow Wing, Dodge,       Aitkin, Anoka, Cook, Hennepin,
                                                 Cass, Clay, Clearwater, Cottonwood,      Kanabec, Lake of the Woods, McLeod,      Lac qui Parle, Lake, Olmsted,
                                                 Dakota, Fillmore, Freeborn, Goodhue,     Mahnomen, Marshall, Mille Lacs,          Pine, Sibley and Stevens counties
                                                 Grant, Hubbard, Isanti, Itasca,          Mower, Murray, Norman, Ramsey,           in Minnesota.
                                                 Jackson, Koochiching, Le Sueur,          Traverse and Yellow Medicine counties
                                                 Meeker, Morrison, Polk, Pope,            in Minnesota.
                                                 Renville, Rice, Roseau, St Louis,
                                                 Scott, Sherburne, Stearns, Steele,
                                                 Swift, Todd, Wabasha, Wadena,
                                                 Waseca, Washington, Watonwan and
                                                 Wright counties in Minnesota.
92




     HospitalInpatient                          Days1-5: $350 co-pay each day.         Days1-5: $350 co-pay each day.         Days1-5: $350 co-pay each day.
                                                 Days6-90: $0 co-pay each day.          Days6-90: $0 co-pay each day.          Days6-90: $0 co-pay each day.
                                                 No limit to the number of days covered   No limit to the number of days covered   No limit to the number of days covered
                                                 by the plan each benefit period.         by the plan each benefit period.         by the plan each benefit period.
     Physician/Outpatient                        $245 hospital co-pay, $145 ambulatory $245 hospital co-pay, $145 ambulatory $245 hospital co-pay, $145 ambulatory
                                                 surgical center co-pay, $25 primary care surgical center co-pay, $25 primary care surgical center co-pay, $25 primary care
                                                 provider co-pay, $50 specialist co-pay.  provider co-pay, $50 specialist co-pay.  provider co-pay, $50 specialist co-pay.




                                                                                                                                                                              MedicareAdvantagePrivate-Fee-For-ServicePlans
     EmergencyServices/UrgentCare              $50 co-pay.                              $50 co-pay.                              $50 co-pay.

     PreventiveServices                         $0 co-pay.                               $0 co-pay.                               $0 co-pay.

     DiagnosticTests,X-raysandLabServices   0% co-insurance laband diagnostic      0% co-insurance laband diagnostic      0% co-insurance laband diagnostic
                                                 procedures, 20% co-insurance radiology. procedures, 20% co-insurance radiology. procedures, 20% co-insurance radiology.
     Physical/Speech/OccupationalTherapy        $50 co-pay.                              $50 co-pay.                              $50 co-pay.

     HomeHealthCare                            20% co-insurance.                        20% co-insurance.                        20% co-insurance.

     MentalHealth                               50% co-insurance.                        50% co-insurance.                        50% co-insurance.

     ChemicalDependency                         50% co-insurance.                        50% co-insurance.                        50% co-insurance.

     SkilledNursingCare                        $100 co-pay days 21-100.                 $100 co-pay days 21-100.                 $100 co-pay days 21-100.
     DurableMedicalEquipment                      20% co-insurance.                      20% co-insurance.                     20% co-insurance.




                                                                                                                                                                       MedicareAdvantagePrivate-Fee-For-ServicePlans
     Dental                                         Medicare-covered only.                 Medicare-covered only.                Medicare-covered only.

     Chiropractic                                   $50 co-pay.                            $50 co-pay.                           $50 co-pay.

     TravelBenefits                                N/A                                    N/A                                   N/A

     MedicarePartBDrugs                          20% co-insurance.                      20% co-insurance.                     20% co-insurance.

     MedicarePartDOutpatientPrescriptions No drug coverage offered through plan. No drug coverage offered through plan. No drug coverage offered through plan.
     Discounts/SpecialPrograms                     None.                                  None.                                 None.

     NumberofProvidersIn-Network                 Contact plan for list of providers.    Contact plan for list of providers.   Contact plan for list of providers.

     EnrollmentStatus/HealthScreening             Open enrollment.                       Open enrollment.                      Open enrollment.

     MaximumAnnualOut-of-PocketCosts             $3,400                                 $3,400                                $3,400

     MonthlyPremiums                               $65                                    $85                                   $100




                                                                                                                                                                                  ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
                                                          QuickTip16
93




                                                          SeniorLinkAgeLine®(1-800-333-2433)

                                                          Areasofexpertiseinclude:
                                                          • Medicare
                                                          • Long-termcareoptionscounseling
                                                          • MinnesotaLong-termCarePartnership
                                                             P
                                                          •  rescriptiondrugexpenseassistance
                                                             forallages
                                                          • CaregiverPlanningandSupport
                                                          • HealthInsurancecounseling
                                                          • Applicationandformsassistance
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                        H
                                                                                                                                                                                         ealthCareChoicesforMinnesotansonMedicare
                                                 www.Universal-American-Medicare.com      www.Universal-American-Medicare.com www.Universal-American-Medicare.com
                           
                                                        Today’sOptionsValue                  Today’sOptionsValue                   Today’sOptionsValue
                                                       poweredbyCCRx(PFFS)                  poweredbyCCRx(PFFS)                    poweredbyCCRx(PFFS)
                                                                 H5421-142                                H5421-150                                 H5421-158
                                                             1-800-996-8867                           1-800-996-8867                            11-800-996-8867
                                                           TTY: 1-800-777-9083                      TTY: 1-800-777-9083                       TTY: 1-800-777-9083
                                                               8 a.m. to 8 p.m.                         8 a.m. to 8 p.m.                          8 a.m. to 8 p.m.
                                                       in your local time zone everyday         in your local time zone everyday          in your local time zone everyday

     ServiceArea                                Blue Earth, Carlton, Chippewa, Houston   Brown, Douglas, Kandiyohi, Kittson, Martin, Faribault, Otter Tail and Red Lake
                                                 and Winona counties in Minnesota.        Nicollet, Nobles, Pennington, Redwood,      counties in Minnesota.
                                                                                          Rock and Wilkin counties in Minnesota.

     HospitalInpatient                          Days1-5: $350 co-pay each day.          Days1-5: $350 co-pay each day.           Days1-5: $350 co-pay each day.
                                                 Days6-90:$0 co-pay each day.          Days6-90:$0 co-pay each day.           Days6-90:$0 co-pay each day.
                                                 No limit to the number of days covered   No limit to the number of days covered    No limit to the number of days covered
                                                 by the plan each benefit period.         by the plan each benefit period.          by the plan each benefit period.
     Physician/Outpatient                        $245 co-pay hospital, $145 co-pay        $245 co-pay hospital, $145 co-pay         $245 co-pay hospital, $145 co-pay
94




                                                 ambulatory surgical center, $25          ambulatory surgical center, $25           ambulatory surgical center, $25
                                                 co-pay primary care provider, $50        co-pay primary care provider, $50         co-pay primary care provider, $50
                                                 co-pay specialist.                       co-pay specialist.                        co-pay specialist.
     EmergencyServices/UrgentCare              $50 ER co-pay, $35 Urgent care co-pay. $50 ER co-pay, $35 Urgent care co-pay. $50 ER co-pay, $35 Urgent care co-pay.

     PreventiveServices                         $0 co-pay.                               $0 co-pay.                                $0 co-pay.

     DiagnosticTests,X-raysandLabServices   0% co-insurance lab and diagnostic       0% co-insurance lab and diagnostic        0% co-insurance lab and diagnostic




                                                                                                                                                                             MedicareAdvantagePrivate-Fee-For-ServicePlans
                                                 procedures, 20% co-insurance             procedures, 20% co-insurance              procedures, 20% co-insurance
                                                 radiology.                               radiology.                                radiology.
     Physical/Speech/OccupationalTherapy        $50 co-pay.                              $50 co-pay.                               $50 co-pay.

     HomeHealthCare                            20% co-insurance.                        20% co-insurance.                         20% co-insurance.

     MentalHealth                               50% co-insurance.                        50% co-insurance.                         50% co-insurance.

     ChemicalDependency                         50% co-insurance.                        50% co-insurance.                         50% co-insurance.

     SkilledNursingCare                        $100 co-pay days 21-100.                 $100 co-pay days 21-100.                  $100 co-pay days 21-100.

     DurableMedicalEquipment                   20% co-insurance.                        20% co-insurance.                         20% co-insurance.

     Dental                                      Medicare-covered only.                   Medicare-covered only.                    Medicare-covered only.

     Chiropractic                                $50 co-pay.                              $50 co-pay.                               $50 co-pay.

     TravelBenefits                             N/A                                      N/A                                       N/A

     MedicarePartBDrugs                       20% co-insurance.                        20% co-insurance.                         20% co-insurance.
                                                                                                                                                               MedicareAdvantagePrivate-Fee-For-ServicePlans
     MedicarePartDOutpatientPrescriptions Deductible:$0                         Deductible:$0                       Deductible:$0
                                               BrandNameDrugs: $35 co-pay.         BrandNameDrugs: $35 co-pay.        BrandNameDrugs: $35 co-pay.
                                               GenericDrugs: $5-$35 co-pay.         GenericDrugs: $5-$35 co-pay.        GenericDrugs: $5-$35 co-pay.
                                               Non-preferredBrand                 Non-preferredBrand                Non-preferredBrand
                                               NameDrugs: $35-$65 co-pay.           NameDrugs: $35-$65 co-pay.          NameDrugs: $35-$65 co-pay.
                                               SpecialtyDrugs: 33% co-insurance.    SpecialtyDrugs: 33% co-insurance.   SpecialtyDrugs: 33% co-insurance.
                                               ShinglesVaccine: $35-$65 co-pay.     ShinglesVaccine: $35-$65 co-pay.    ShinglesVaccine: $35-$65 co-pay.
                                               Mail order is not available.          Mail order is not available.         Mail order is not available.
                                               Contact plan for list of network      Contact plan for list of network     Contact plan for list of network
                                               pharmacies.                           pharmacies.                          pharmacies.
     Discounts/SpecialPrograms                None.                                 None.                                None.

     NumberofProvidersIn-Network            Contact plan for more information.    Contact plan for more information.   Contact plan for more information.

     EnrollmentStatus/HealthScreening        Open enrollment.                      Open enrollment.                     Open enrollment.

     MaximumAnnualOut-of-PocketCosts        $3,400                                $3,400                               $3,400

     MonthlyPremiums                          PlanOnly: $20                        PlanOnly: $17                       PlanOnly: $53
                                               PlanwithPartDPremium: $26         PlanwithPartDPremium: $23        PlanwithPartDPremium: $63




                                                                                                                                                                          ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
95




                                              QuickTip17
                                              Makesuretogetyourone-timeWelcometoMedicare
                                              physicalexamwithin12monthsofsigningupfor
                                              MedicarePartB.TheWelcometoMedicarephysical
                                              examincludes:
                                                 R
                                              •  eviewofmedicalhistory,includingpreventive
                                                 screeningsandservices
                                              • Bloodpressure,vision,heightandweightchecks
                                                 I
                                              • nformationaboutend-of-lifeplanning,including
                                                 advancedirectives
                                                 A
                                              •  writtenplanforyoutofollowwithyourscreenings
                                                 andotherpreventiveservicesyoushouldget.
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                       H
                                                                                                                                                                                        ealthCareChoicesforMinnesotansonMedicare
                                                 www.Universal-American-Medicare.com www.Universal-American-Medicare.com www.Universal-American-Medicare.com
                           
                                                      Today’sOptionsValue                  Today’sOptionsValue                  Today’sOptionsValue
                                                     poweredbyCCRx(PFFS)                  poweredbyCCRx(PFFS)                  poweredbyCCRx(PFFS)
                                                                H5421-166                               H5421-174                                H5421-182
                                                            1-800-996-8867                          1-800-996-8867                           1-800-996-8867
                                                          TTY: 1-800-777-9083                     TTY: 1-800-777-9083                      TTY: 1-800-777-9083
                                                              8 a.m. to 8 p.m.                        8 a.m. to 8 p.m.                         8 a.m. to 8 p.m.
                                                      in your local time zone everyday        in your local time zone everyday         in your local time zone everyday

     ServiceArea                                Becker, Beltrami, Benton, Big Stone,     Carver, Chisago, Crow Wing, Dodge,       Aitkin, Anoka, Cook, Hennepin,
                                                 Cass, Clay, Clearwater, Cottonwood,      Kanabec, Lake of the Woods,              Lac qui Parle, Lake, Olmsted, Pine,
                                                 Dakota, Fillmore, Freeborn, Goodhue,     Mahnomen, Marshall, McLeod,              Sibley and Stevens counties in
                                                 Grant, Hubbard, Isanti, Itasca,          Mille Lacs, Mower, Murray, Norman,       Minnesota.
                                                 Jackson, Koochiching, Le Sueur,          Ramsey, Traverse and Yellow Medicine
                                                 Meeker, Morrison, Polk, Pope,            counties in Minnesota.
                                                 Renville, Rice, Roseau, Scott,
                                                 Sherburne, St Louis, Stearns, Steele,
                                                 Swift, Todd, Wabasha, Wadena,
96




                                                 Waseca, Washington, Watonwan and
                                                 Wright counties in Minnesota.

     HospitalInpatient                          Days1-5: $350 co-pay each day.          Days1-5: $350 co-pay each day.          Days1-5: $350 co-pay each day.
                                                 Days6-90:$0 co-pay each day.          Days6-90:$0 co-pay each day.          Days6-90:$0 co-pay each day.
                                                 No limit to the number of days covered   No limit to the number of days covered   No limit to the number of days covered
                                                 by the plan each benefit period.         by the plan each benefit period.         by the plan each benefit period.




                                                                                                                                                                            MedicareAdvantagePrivate-Fee-For-ServicePlans
     Physician/Outpatient                        $245 co-pay hospital, $145 co-pay        $245 co-pay hospital, $145 co-pay        $245 co-pay hospital, $145 co-pay
                                                 ambulatory surgical center, $25          ambulatory surgical center, $25          ambulatory surgical center, $25
                                                 co-pay primary care provider, $50        co-pay primary care provider, $50        co-pay primary care provider, $50
                                                 co-pay specialist.                       co-pay specialist.                       co-pay specialist.
     EmergencyServices/UrgentCare              $50 ER co-pay, $35 Urgent care co-pay. $50 ER co-pay, $35 Urgent care co-pay. $50 ER co-pay, $35 Urgent care co-pay.

     PreventiveServices                         $0 co-pay.                               $0 co-pay.                               $0 co-pay.

     DiagnosticTests,X-raysandLabServices 0% co-insurance lab and diagnostic         0% co-insurance lab and diagnostic       0% co-insurance lab and diagnostic
                                                 procedures, 20% co-insurance             procedures, 20% co-insurance             procedures, 20% co-insurance
                                                 radiology.                               radiology.                               radiology.
     Physical/Speech/OccupationalTherapy        $50 co-pay.                              $50 co-pay.                              $50 co-pay.

     HomeHealthCare                            20% co-insurance.                        20% co-insurance.                        20% co-insurance.

     MentalHealth                               50% co-insurance.                        50% co-insurance.                        50% co-insurance.

     ChemicalDependency                         50% co-insurance.                        50% co-insurance.                        50% co-insurance.

     SkilledNursingCare                        $100 co-pay days 21-100.                 $100 co-pay days 21-100.                 $100 co-pay days 21-100.
                                                                                                                                                                 MedicareAdvantagePrivate-Fee-For-ServicePlans
     DurableMedicalEquipment                 20% co-insurance.                     20% co-insurance.                     20% co-insurance.

     Dental                                    Medicare-covered only.                Medicare-covered only.                Medicare-covered only.

     Chiropractic                              $50 co-pay.                           $50 co-pay.                           $50 co-pay.

     TravelBenefits                           N/A                                   N/A                                   N/A

     MedicarePartBDrugs                     20% co-insurance.                     20% co-insurance.                     20% co-insurance.

     MedicarePartDOutpatientPrescriptions Deductible: $310                       Deductible: $310                      Deductible: $310
                                               BrandNameDrugs: 25% copay.         BrandNameDrugs: 25% copay.         BrandNameDrugs: 25% copay.
                                               GenericDrugs: 25% co-insurance.      GenericDrugs: 25% co-insurance.      GenericDrugs: 25% co-insurance.
                                               Non-preferredBrand                 Non-preferredBrand                 Non-preferredBrand
                                               NameDrugs: 25% co-insurance.         NameDrugs: 25% co-insurance.         NameDrugs: 25% co-insurance.
                                               SpecialtyDrugs: 25% co-insurance.    SpecialtyDrugs: 25% co-insurance.    SpecialtyDrugs: 25% co-insurance.
                                               ShinglesVaccine: 25% co-insurance.   ShinglesVaccine: 25% co-insurance.   ShinglesVaccine: 25% co-insurance.
                                               Mail order is not available.          Mail order is not available.          Mail order is not available.
                                               Contact plan for list of network      Contact plan for list of network      Contact plan for list of network
                                               pharmacies.                           pharmacies.                           pharmacies.
     Discounts/SpecialPrograms                None.                                 None.                                 None.

     NumberofProvidersIn-Network            Contact plan for list of providers.   Contact plan for list of providers.   Contact plan for list of providers.




                                                                                                                                                                            ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
     EnrollmentStatus/HealthScreening        Open enrollment.                      Open enrollment.                      Open enrollment.

     MaximumAnnualOut-of-PocketCosts        $3,400                                $3,400                                $3,400
97




     MonthlyPremiums                          PlanOnly: $66                        PlanOnly: $85                        PlanOnly: $100
                                               PlanwithPartDPremium: $76         PlanwithPartDPremium: $99         PlanwithPartDPremium: $114




                                               QuickTip18
                                               Anombudsmanisanindependentconsumeradvocate.
                                                
                                                I
                                               • nMinnesota,theOfficeofOmbudsmanforLong-term
                                                Careprovidesinformationandconsultationaboutyour
                                                rightsthatapplytolong-termcarefacilities,homeand
                                                communitybasedsettingsandhomecareservices.
                                                
                                                T
                                               • heOmbudsmaninvestigateslong-termcareconsumer
                                                complaints,workstoresolveindividualconcernsand
                                                identifyproblemsaswellasadvocateforchangesto
                                                resolvetheproblems.
                                                
                                                C
                                               • all1-800-657-3591togetconnectedtotheMinnesota
                                                OfficeofOmbudsmanforLong-termCare.
     MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                         H
                                                                                                                                                                                          ealthCareChoicesforMinnesotansonMedicare
                                                  www.Universal-American-Medicare.com       www.Universal-American-Medicare.com www.Universal-American-Medicare.com
                           
                                                     Today’sOptionsPremier                  Today’sOptionsPremier                 Today’sOptionsPremier
                                                                H5421-163                                 H5421-171                                 H5421-179
                                                            1-800-996-8867                            1-800-996-8867                            11-800-996-8867
                                                          TTY: 1-800-777-9083                       TTY: 1-800-777-9083                       TTY: 1-800-777-9083
                                                              8 a.m. to 8 p.m.                          8 a.m. to 8 p.m.                          8 a.m. to 8 p.m.
                                                      in your local time zone everyday          in your local time zone everyday          in your local time zone everyday
     ServiceArea                                Becker, Beltrami, Benton, Big Stone,       Carver, Chisago, Crow Wing, Dodge,       Aitkin, Anoka, Cook, Hennepin,
                                                 Cass, Clay, Clearwater, Cottonwood,        Kanabec, Lake of the Woods, McLeod,      Lac qui Parle, Lake, Olmsted, Pine,
                                                 Dakota, Fillmore, Freeborn, Goodhue,       Mahnomen, Marshall, Mille Lacs,          Sibley and Stevens counties in
                                                 Grant, Hubbard, Isanti, Itasca, Jackson,   Mower, Murray, Norman, Ramsey,           Minnesota.
                                                 Koochiching, Le Sueur, Meeker,             Traverse and Yellow Medicine counties
                                                 Morrison, Polk, Pope, Renville, Rice,      in Minnesota.
                                                 Roseau, St Louis, Scott, Sherburne,
                                                 Stearns, Steele, Swift, Todd, Wabasha,
                                                 Wadena, Waseca, Washington, Watonwan
                                                 and Wright counties in Minnesota.
98




     HospitalInpatient                          Days1-5: $250 co-pay each day.           Days1-5: $250 co-pay each day.         Days1-5: $250 co-pay each day.
                                                 Days6-90: $0 co-pay each day.            Days6-90: $0 co-pay each day.          Days6-90: $0 co-pay each day.
                                                 No limit to the number of days covered     No limit to the number of days covered   No limit to the number of days covered
                                                 by the plan each benefit period.           by the plan each benefit period.         by the plan each benefit period.
     Physician/Outpatient                        $150 co-pay hospital, $75 co-pay           $150 co-pay hospital, $75 co-pay         $150 co-pay hospital, $75 co-pay
                                                 ambulatory surgical center, $15            ambulatory surgical center, $15          ambulatory surgical center, $15
                                                 co-pay primary care provider, $40          co-pay primary care provider, $40        co-pay primary care provider, $40




                                                                                                                                                                              MedicareAdvantagePrivate-Fee-For-ServicePlans
                                                 co-pay specialist.                         co-pay specialist.                       co-pay specialist.
     EmergencyServices/UrgentCare              $50 ER co-pay, $35 Urgent care co-pay.     $50 ER co-pay, $35 Urgent care co-pay.   $50 ER co-pay, $35 Urgent care co-pay.

     PreventiveServices                         $0 co-pay.                                 $0 co-pay.                               $0 co-pay.

     DiagnosticTests,X-raysandLabServices 0% laband diagnostic procedures,            0% laband diagnostic procedures,        0% laband diagnostic procedures,
                                                 20% radiology.                             20% radiology.                           20% radiology.
     Physical/Speech/OccupationalTherapy        $15 co-pay.                                $15 co-pay.                              $15 co-pay.

     HomeHealthCare                            15% co-insurance.                          15% co-insurance.                        15% co-insurance.

     MentalHealth                               50% co-insurance.                          50% co-insurance.                        50% co-insurance.

     ChemicalDependency                         50% co-insurance.                          50% co-insurance.                        50% co-insurance.

     SkilledNursingCare                        $100 co-pay days 21-100.                   $100 co-pay days 21-100.                 $100 co-pay days 21-100.

     DurableMedicalEquipment                   20% co-insurance.                          20% co-insurance.                        20% co-insurance.

     Dental                                      Medicare-covered only services.            Medicare-covered only services.          Medicare-covered only services.
                                                                                                                                                                          MedicareAdvantagePrivate-Fee-For-ServicePlans
     Chiropractic                                  $40 co-pay.                            $40 co-pay.                            $40 co-pay.

     TravelBenefits                               N/A                                    N/A                                    N/A

     MedicarePartBDrugs                         20% co-insurance.                      20% co-insurance.                      20% co-insurance.

     MedicarePartDOutpatientPrescriptions      No drug coverage offered through plan. No drug coverage offered through plan. No drug coverage offered through plan.

     Discounts/SpecialPrograms                    None.                                  None.                                  None.

     NumberofProvidersIn-Network                Contact plan for list of providers.    Contact plan for list of providers.    Contact plan for list of providers.

     EnrollmentStatus/HealthScreening            Open enrollment.                       Open enrollment.                       Open enrollment.

     MaximumAnnualOut-of-PocketCosts            $3,400                                 $3,400                                 $3,400

     MonthlyPremiums                              $104                                   $124                                   $134




                                                QuickTip19




                                                                                                                                                                                     ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
                                                Whenmakingdecisionsaboutyourhealthcare,housing,
                                                long-termcare,caregivermatters,andothermajorlife
99




                                                changingdecisions,itisbestto:
                                                •Askforhelp
                                                •Findoutaboutallofyouroptions
                                                  A
                                                • skquestionsandkeepaskinguntilyoufullyunderstand
                                                  youroptions
                                                  B
                                                • eawarethatthereisfreeobjectivehelpavailableto
                                                  younomatterwhereyouliveinMinnesotabycallingthe
                                                  SeniorLinkAgeLine®at1-800-333-2433orvisiting
                                                  www.MinnesotaHelp.info®
      MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                        H
                                                                                                                                                                                         ealthCareChoicesforMinnesotansonMedicare
                                                  www.Universal-American-Medicare.com www.Universal-American-Medicare.com www.Universal-American-Medicare.com
                            
                                                        Today’sOptionsPremier                Today’sOptionsPremier                Today’sOptionsPremier
                                                        poweredbyCCRx(PFFS)                  poweredbyCCRx(PFFS)                  poweredbyCCRx(PFFS)
                                                                  H5421-140                                H5421-148                                H5421-156
                                                              1-800-996-8867                           1-800-996-8867                           1-800-996-8867
                                                            TTY: 1-800-777-9083                      TTY: 1-800-777-9083                      TTY: 1-800-777-9083
                                                                8 a.m. to 8 p.m.                         8 a.m. to 8 p.m.                         8 a.m. to 8 p.m.
                                                        in your local time zone everyday         in your local time zone everyday         in your local time zone everyday
      ServiceArea                                Blue Earth, Carlton, Chippewa,           Brown, Douglas, Kandiyohi, Kittson,   Faribault, Otter Tail and Red Lake
                                                  Houston and Winona counties in           Martin, Nicollet, Nobles, Pennington, counties in Minnesota.
                                                  Minnesota.                               Redwood, Rock and Wilkin counties in
                                                                                           Minnesota.

      HospitalInpatient                          Days1-5:$250 co-pay each day.          Days1-5:$250 co-pay each day.          Days1-5:$250 co-pay each day.
                                                  Days6-90: $0 co-pay each day.          Days6-90: $0 co-pay each day.          Days6-90: $0 co-pay each day.
                                                  No limit to the number of days covered   No limit to the number of days covered   No limit to the number of days covered
                                                  by the plan each benefit period.         by the plan each benefit period.         by the plan each benefit period.
100




      Physician/Outpatient                        $150 co-pay hospital, $75 co-pay         $150 co-pay hospital, $75 co-pay         $150 co-pay hospital, $75 co-pay
                                                  ambulatory surgical center, $15          ambulatory surgical center, $15          ambulatory surgical center, $15
                                                  co-pay primary care provider, $40        co-pay primary care provider, $40        co-pay primary care provider, $40
                                                  co-pay specialist.                       co-pay specialist.                       co-pay specialist.
      EmergencyServices/UrgentCare              $50 ER co-pay, $35 Urgent care co-pay.   $50 ER co-pay, $35 Urgent care co-pay.   $50 ER co-pay, $35 Urgent care co-pay.

      PreventiveServices                         $0 co-pay.                               $0 co-pay.                               $0 co-pay.




                                                                                                                                                                             MedicareAdvantagePrivate-Fee-For-ServicePlans
      DiagnosticTests,X-raysandLabServices   0% co-insurance laband diagnostic      0% co-insurance laband diagnostic      0% co-insurance laband diagnostic
                                                  procedures, 20% co-insurance radiology. procedures, 20% co-insurance radiology. procedures, 20% co-insurance radiology.
      Physical/Speech/OccupationalTherapy        $15 co-pay.                              $15 co-pay.                              $15 co-pay.

      HomeHealthCare                            15% co-insurance.                        15% co-insurance.                        15% co-insurance.

      MentalHealth                               50% co-insurance.                        50% co-insurance.                        50% co-insurance.

      ChemicalDependency                         50% co-insurance.                        50% co-insurance.                        50% co-insurance.

      SkilledNursingCare                        $100 co-pay days 21-100.                 $100 co-pay days 21-100.                 $100 co-pay days 21-100.

      DurableMedicalEquipment                   20% co-insurance.                        20% co-insurance.                        20% co-insurance.

      Dental                                      Medicare-covered only services.          Medicare-covered only services.          Medicare-covered only services.

      Chiropractic                                $40 co-pay.                              $40 co-pay.                              $40 co-pay.

      TravelBenefits                             N/A                                      N/A                                      N/A

      MedicarePartBDrugs                       20% co-insurance.                        20% co-insurance.                        20% co-insurance.
                                                                                                                                                                  MedicareAdvantagePrivate-Fee-For-ServicePlans
      MedicarePartDOutpatientPrescriptions Deductible:$0                         Deductible:$0                        Deductible:$0
                                                BrandNameDrugs: $35 co-pay.         BrandNameDrugs: $35 co-pay.         BrandNameDrugs: $35 co-pay.
                                                GenericDrugs: $5 co-pay.             GenericDrugs: $5 co-pay.             GenericDrugs: $5 co-pay.
                                                Non-preferredBrand                 Non-preferredBrand                 Non-preferredBrand
                                                NameDrugs: $65 co-pay.               NameDrugs: $65 co-pay.               NameDrugs: $65 co-pay.
                                                SpecialtyDrugs: 33% co-insurance.    SpecialtyDrugs: 33% co-insurance.    SpecialtyDrugs: 33% co-insurance.
                                                ShinglesVaccine: $65 co-pay.         ShinglesVaccine: $65 co-pay.         ShinglesVaccine: $65 co-pay.
                                                DonutHoleCoverage: Generics only.   DonutHoleCoverage: Generics only.   DonutHoleCoverage: Generics only.
                                                Mail order is not available.          Mail order is not available.          Mail order is not available.
                                                Contact plan for list of network      Contact plan for list of network      Contact plan for list of network
                                                pharmacies.                           pharmacies.                           pharmacies.
      Discounts/SpecialPrograms                None.                                 None.                                 None.

      NumberofProvidersIn-Network            Contact plan for list of providers.   Contact plan for list of providers.   Contact plan for list of providers.

      EnrollmentStatus/HealthScreening        Open enrollment.                      Open enrollment.                      Open enrollment.

      MaximumAnnualOut-of-PocketCosts        $3,400                                $3,400                                $3,400

      MonthlyPremiums                          PlanOnly: $47                        PlanOnly: $81                        PlanOnly: $99
                                                PlanwithPartDPremium: $64         PlanwithPartDPremium: $120        PlanwithPartDPremium: $146




                                                                                                                                                                             ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
101




                                                QuickTip20
                                                TheMinnesotaHelpNetwork™islookingfornewpartners
                                                tohelpexpandthelocalaccessandoutreachsitesinall87
                                                countiesofMinnesota.Togetmoreinformationaboutbecoming
                                                asite,aswellasfreetrainingandmaterials,calltheSenior
                                                LinkAgeLine®at1-800-333-2433.EachAreaAgencyon
                                                Agingmanagestheaccessandoutreachsitesthroughthe
                                                SeniorLinkAgeLine®.
      MedicareAdvantagePrivate-Fee-For-ServicePlans




                                                                                                                                                                                        H
                                                                                                                                                                                         ealthCareChoicesforMinnesotansonMedicare
                                                  www.Universal-American-Medicare.com      www.Universal-American-Medicare.com      www.Universal-American-Medicare.com
                                                      Today’sOptionsPremier                Today’sOptionsPremier                Today’sOptionsPremier
                                                      poweredbyCCRx(PFFS)                  poweredbyCCRx(PFFS)                  poweredbyCCRx(PFFS)
                                                               H5421-164                                H5421-172                                H5421-180
                                                            1-800-996-8867                           1-800-996-8867                           1-800-996-8867
                                                          TTY: 1-800-777-9083                      TTY: 1-800-777-9083                      TTY: 1-800-777-9083
                                                              8 a.m. to 8 p.m.                         8 a.m. to 8 p.m.                         8 a.m. to 8 p.m.
                                                      in your local time zone everyday         in your local time zone everyday         in your local time zone everyday
      ServiceArea                                Becker, Beltrami, Benton, Big Stone,     Carver, Chisago, Crow Wing, Dodge,       Aitkin, Anoka, Cook, Hennepin,
                                                  Cass, Clay, Clearwater, Cottonwood,      Kanabec, Lake of the Woods,              Lac qui Parle, Lake, Olmsted, Pine,
                                                  Dakota, Fillmore, Freeborn, Goodhue,     Mahnomen, Marshall, McLeod,              Sibley and Stevens counties in
                                                  Grant, Hubbard, Isanti, Itasca,          Mille Lacs, Mower, Murray, Norman,       Minnesota.
                                                  Jackson, Koochiching, Le Sueur,          Ramsey, Traverse and Yellow Medicine
                                                  Meeker, Morrison, Polk, Pope,            counties in Minnesota.
                                                  Renville, Rice, Roseau, Scott,
                                                  Sherburne, St Louis, Stearns, Steele,
                                                  Swift, Todd, Wabasha, Wadena,
102




                                                  Waseca, Washington, Watonwan and
                                                  Wright counties in Minnesota.
      HospitalInpatient                          Days1-5:$250 co-pay each day.          Days1-5:$250 co-pay each day.          Days1-5:$250 co-pay each day.
                                                  Days6-90: $0 co-pay each day.          Days6-90: $0 co-pay each day.          Days6-90: $0 co-pay each day.
                                                  No limit to the number of days covered   No limit to the number of days covered   No limit to the number of days covered
                                                  by the plan each benefit period.         by the plan each benefit period.         by the plan each benefit period.




                                                                                                                                                                             MedicareAdvantagePrivate-Fee-For-ServicePlans
      Physician/Outpatient                        $150 co-pay hospital, $75 co-pay         $150 co-pay hospital, $75 co-pay         $150 co-pay hospital, $75 co-pay
                                                  ambulatory surgical center, $15          ambulatory surgical center, $15          ambulatory surgical center, $15
                                                  co-pay primary care provider, $40        co-pay primary care provider, $40        co-pay primary care provider, $40
                                                  co-pay specialist.                       co-pay specialist.                       co-pay specialist.

      EmergencyServices/UrgentCare              $50 ER co-pay, $35 Urgent care co-pay.   $50 ER co-pay, $35 Urgent care co-pay.   $50 ER co-pay, $35 Urgent care co-pay.

      PreventiveServices                         $0 co-pay.                               $0 co-pay.                               $0 co-pay.

      DiagnosticTests,X-raysandLabServices   0% co-insurance laband diagnostic      0% co-insurance laband diagnostic      0% co-insurance laband diagnostic
                                                  procedures, 20% co-insurance radiology. procedures, 20% co-insurance radiology. procedures, 20% co-insurance radiology.
      Physical/Speech/OccupationalTherapy        $15 co-pay.                              $15 co-pay.                              $15 co-pay.

      HomeHealthCare                            15% co-insurance.                        15% co-insurance.                        15% co-insurance.

      MentalHealth                               50% co-insurance.                        50% co-insurance.                        50% co-insurance.

      ChemicalDependency                         50% co-insurance.                        50% co-insurance.                        50% co-insurance.

      SkilledNursingCare                        $100 co-pay days 21-100.                 $100 co-pay days 21-100.                 $100 co-pay days 21-100.

      DurableMedicalEquipment                   20% co-insurance.                        20% co-insurance.                        20% co-insurance.
                                                                                                                                                                     MedicareAdvantagePrivate-Fee-For-ServicePlans
      Dental                                       Medicare-covered only services.       Medicare-covered only services.       Medicare-covered only services.

      Chiropractic                                 $40 co-pay.                           $40 co-pay.                           $40 co-pay.

      TravelBenefits                              N/A                                   N/A                                   N/A

      MedicarePartBDrugs                        20% co-insurance.                     20% co-insurance.                     20% co-insurance.

      MedicarePartDOutpatientPrescriptions     Deductible:$0                        Deductible:$0                        Deductible:$0
                                                   BrandNameDrugs: $35 co-pay.         BrandNameDrugs: $35 co-pay.         BrandNameDrugs: $35 co-pay.
                                                   GenericDrugs: $5 co-pay.             GenericDrugs: $5 co-pay.             GenericDrugs: $5 co-pay.
                                                   Non-preferredBrand                 Non-preferredBrand                 Non-preferredBrand
                                                   NameDrugs: $65 co-pay.               NameDrugs: $65 co-pay.               NameDrugs: $65 co-pay.
                                                   SpecialtyDrugs: 33% co-insurance.    SpecialtyDrugs: 33% co-insurance.    SpecialtyDrugs: 33% co-insurance.
                                                   ShinglesVaccine: $65 co-pay.         ShinglesVaccine: $65 co-pay.         ShinglesVaccine: $65 co-pay.
                                                   DonutHoleCoverage: Generics only.   DonutHoleCoverage: Generics only.   DonutHoleCoverage: Generics only.
                                                   Mail order is not available.          Mail order is not available.          Mail order is not available.
                                                   Contact plan for list of network      Contact plan for list of network      Contact plan for list of network
                                                   pharmacies.                           pharmacies.                           pharmacies.
      Discounts/SpecialPrograms                   None.                                 None.                                 None.

      NumberofProvidersIn-Network               Contact plan for list of providers.   Contact plan for list of providers.   Contact plan for list of providers.




                                                                                                                                                                                ApublicationoftheMinnesotaBoardonAgingSeniorLinkAgeLine®
      EnrollmentStatus/HealthScreening           Open enrollment.                      Open enrollment.                      Open enrollment.

      MaximumAnnualOut-of-PocketCosts           $3,400                                $3,400                                $3,400

      MonthlyPremiums                             PlanOnly: $107                       PlanOnly: $135                       PlanOnly: $150
103




                                                   PlanwithPartDPremium: $151        PlanwithPartDPremium: $186        PlanwithPartDPremium: $203




                                                 QuickTip21
                                                 Getyourfree,individualizedplanthroughthe
                                                 Long-termCareChoicesNavigatorforSeniors,
                                                 FamiliesandCaregiversathttp://longtermcarechoices.
                                                 minnesotahelp.info.Yourplanwillhelpyoufigureout
                                                 whatyouneedtolivewellandagewell,including
                                                 providingyouwithlocalcommunityresources.

				
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Description: Health Care Choices unicare1